As people age, pelvic muscles weaken. This can lead to the stress urinary incontinence, a medical condition that causes urine to leak during normal activities that place pressure on the bladder. Activities that can cause urine to leak include coughing, sneezing, laughing or exercising.
To control urination, the body uses two muscles called the sphincter and the detrusor. The sphincter is a muscle that wraps around the urethra tube, a tube that carries urine out of the body. Squeezing the sphincter stops the flow of urine. The detrusor is the bladder wall muscle. It must be relaxed for the bladder to fill with urine and contracted for it to empty.
The sphincter and the detrusor both contribute to the pelvic muscle which restricts urine flow
If the pressure between these two muscles is even, a person will remain continent. When pressure on the urethra decreases but pressure increases on the bladder, a person has the urge to urinate and they urinate normally. However, someone suffering from stress urinary incontinence loses control of the sphincter. They are unable to control the pressures, causing leakage.
SUI is rare in men, but 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, it is underreported and underdiagnosed. In a 2004 National Institutes of Health study, the rate of SUI in women in the United States varied between 4 percent and 35 percent. The U.S. Food and Drug Administration 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.
SUI affects quality of life because it interferes with romantic relationships, social life, work and other activities.
Stress Urinary Incontinence Causes
Stress urinary incontinence most often occurs in women who have had more than one vaginal childbirth. A woman’s uterus causes anatomical changes in the urethra and bladder during pregnancy. Hormonal changes during pregnancy can also affect the pelvic floor, increasing the risk of SUI.
Pelvic muscles also change during the second stage of labor. There is also debate about whether the use of forceps during delivery injures pelvic muscles. Multiplevaginal deliveries can further jeopardize a woman’s urinary tract.
Other causes of SUI include:
- Age — Pelvic muscles and tissues usually lose elasticity and weaken over time. Menopause can lower estrogen levels, increasing the risk for SUI.
- Obesity — Excess weight puts unnecessary strain on the bladder and urethra.
- Smoking — Chronic coughing from smoking increases pressure on the bladder and urethra.
- Pelvic surgery (including hysterectomy) — Surgery can weaken or damage pelvic muscles.
- 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.
People can reduce their risk for stress urinary incontinence by addressing several risk factors. Losing weight, quitting smoking and lowering caffeine consumption can help prevent stress urinary incontinence.
Symptoms of Stress Urinary Incontinence
Involuntary loss of urine is a sign of stress urinary incontinence. Leaking urine does not have to happen frequently or in great volumes. Any regular loss of urine — even small drops — is considered SUI.
Unfortunately, stress urinary incontinence often occurs during the inopportune times, and SUI is not preceded by the urge to urinate.
Physical activities that put pressure on the bladder and urethra often cause 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 sexual intercourse can be the culprits as well.
Because of the range in severity of SUI, there are many ways to evaluate and treat the condition.
Even slight Urine leakage is classified as SUI
Diagnosing Stress Urinary Incontinence
Stress urinary incontinence is usually noticed by the patient. It isn’t screened for during normal checkups. When a patient complains of incontinence, a primary care doctor uses a pelvic exam or rectal exam to assess the pelvic floor.
The doctor will ask the patient to describe the episodes of leakage. They may also ask them to keep a bladder journal. In addition, the doctor will ask about medical history and take a urine sample to test for abnormalities.
After making a diagnosis, the doctor will discuss how lifestyle factors, such as diet and exercise, can affect SUI. The doctor may refer the patient to a urologist or urogynecologist for confirmation of the type of incontinence and a detailed treatment plan.
These specialists may perform any of the following tests:
- Blood work
- X-rays with contrast
- Urinary stress test
A urinary stress test can be performed in the doctor’s office. It 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 agent, sedative or anesthesia to avoid discomfort.
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. That’s why patients may want to see a specialist to direct their care.
Doctors often begin treatment by suggesting the least-invasive options. Patients experiencing minimal leakage may be comfortable wearing absorbent pads and avoiding invasive procedures. They may also be willing to make some lifestyle changes to lessen symptoms of SUI.
Behavior modifications include:
- Weight loss (for patients who are obese)
- Reducing caffeine intake
- Reducing alcohol intake
- Avoiding irritating substances, such as spicy food
- Avoiding strenuous activities
- Practicing Kegel exercises that strengthen the pelvic muscles
Different drug therapies can treat SUI. Collagen injections help build up the area around the urethra, preventing urine leakage.
Medications that can be used for mild to moderate incontinence 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
Female patients also might be given the option of using a vaginal pessary, which is a removable silicone device that’s inserted into the vagina to provide pelvic support. It must be taken out for periodic cleaning. Topical estrogen is sometimes used in conjunction with a pessary for lubrication and to reduce irritation.
To repair SUI, surgical bladder slings are threaded under the urethra in order to raise and support the urethra tube
To repair SUI, a doctor can create an abdominal incision before stitching 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 tissue or from transvaginal mesh. The bladder sling is threaded under the urethra and anchored on both sides, raising and supporting the urethra tube. Wider slings also compress the bladder and urethra to prevent leakage.
Since their debut in the 1990s, transvaginal mesh 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 vagina (transvaginally).
Unfortunately, mesh bladder slings have been linked to serious complications. Between 2008 and 2010, the FDA received 1,371 reports of complications associated with transvaginal bladder slings.
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 mesh 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.
Other surgical options include:
- Bladder repositioning — Using a patient’s own tissues to reinforce the bladder wall.
- Anteroir vaginal repair — Restoring weak or sagging vaginal walls.
- Retropubic suspension — Lifting the bladder and urethra
When patients don’t find relief from non-surgical options but they wish to avoid surgery, they often choose to use a catheter. A catheter is a tube inserted into the bladder. It drains urine into an external bag.
Stress urinary incontinence is an uncomfortable condition that disrupts daily activity, but there are several treatment options that can help people avoid urine leakage. SUI is not a life-threatening or debilitating condition, so patients should carefully choose the best treatment option for them. Risky treatment options, such as surgeries involving transvaginal mesh, may have more risks than benefits.