Stress urinary incontinence (SUI) is urinary leakage that occurs with coughing, sneezing, jumping, or other activities that may place sudden pressure or “stress” on the bladder. SUI can also be associated with urine leakage during intercourse.
Stress incontinence is caused by a loss of the natural support structures around the urethra. About 1 in 3 women have stress urinary incontinence. Although SUI is a common problem, it is not a “normal part of aging” and several treatment options are available. SUI is less common in men, but can occur after certain types of surgery or injuries.
Stress Urinary Incontinence
What Causes Stress Urinary Incontinence?
Most likely, women develop stress incontinence as a result of multiple risk factors, including an underlying tendency for weaker supporting tissues in some patients. However, several factors may increase your risk:
Pregnancy and childbirth, which can weaken pelvic floor structures
Neurological conditions that damage the nerves of the pelvic floor such as multiple sclerosis, spina bifida and spinal cord injuries
Increasing age
Obesity
Chronic cough, especially in patients who use tobacco, which can also weaken tissues
Menopause, due to hormone changes
Pelvic surgery or radiation treatment
Men may rarely develop stress incontinence, typically after surgeries on the prosate and/ or bladder.
Evaluation of Stress Urinary Incontinence
Urinary incontinence may be difficult or embarrassing to discuss. However, talking with your Urologist is the first step to finding relief. The initial evaluation will primarily involve a thorough history and discussion about your urinary symptoms. There are multiple types of incontinence, so characterizing your specific complaints is very important to making the most appropriate treatment plan. See a bladder assessment.
Other parts of the initial evaluation will likely involve
A urinalysis to evaluate for infection or blood in the urine
A bladder scan to evaluate how well you empty your bladder during each void. This is a specialized ultrasound machine that measures the volume of urine within the bladder. The bladder scan takes about 60 seconds and is painless.
A physical examination of the abdomen, bladder and urethra may be necessary.
Often, we will be able to make an initial treatment plan based on the above information. However, some patients, especially those reporting multiple types of incontinence, may need a more advanced evaluation:
Cystoscopy involves the insertion of a small scope into the urethra. This allows me to examine the urethra and bladder from the inside to confirm there are no abnormalities that may cause your bladder problems. A cystoscopy lasts about 5 minutes and is often done without anesthesia, instead using a numbing gel inserted into the urethra. Sedation is available for patients who prefer this. Learn more about cystoscopy at the AUA Cares Foundation.
Urodynamics is a functional test that help me understand exactly how the urethra and bladder function. This may help demonstrate the cause of certain urinary problems if the cause is not clear from history and a basic examination alone. Urodynamic testing is performed with a very small catheter inserted into the bladder. This catheter is connected to a sensor, which can sense the pressures inside the bladder and the urethra during certain phases of bladder filling and bladder emptying. The test is relatively painless and lasts 30-45 minutes. Learn more about urodynamic testing at the AUA Cares Foundation.
Conservative Treatment Options
Lifestyle changes such as weight loss and pelvic floor strengthening can help decrease urinary leakage.
Even a small amount of weight loss may make a significant impact on leakage associated with stress urinary incontinence. Research has found that a loss of as little as 8% of body weight can have an impact.
Pelvic floor strengthening exercises are more commonly known as “kegel exercises.” A kegel exercise involves contracting the pelvic floor around the vagina and urethra. To identify these muscles, practice contracting the muscles that would cut off the flow of urine mid-stream. Some patients benefit from a referral to a pelvic floor physical therapist to help identify these muscles and provide education on types of exercises that can strengthen the pelvic floor. Learn more at VoicesforPFD.org.
An incontinence pessary is a device that is inserted into the vagina to help support the urethra and prevent leakage. There are options for a device that can stay in place for several months at a time and options that you can insert only when needed. Learn more at VoicesforPFD.org.
Keeping a bladder diary, which tracks your fluid intake, urine output and trips to the bathroom for a few days, can help you understand your body better. This diary may show you things that make symptoms better or worse. See an example of a bladder diary.
Timed voiding involves voiding based on a set scheduled to help you remember to regularly empty the bladder. The schedule is designed to empty your bladder before you would typically have leakage.
Procedural Treatment Options
Stress urinary incontinence is primarily a structural or anatomical problem. Thus, medications are not typically indicated. If conservative treatments are not successful, there are several procedures that may be considered:
Urethral Bulking Procedure:
During a urethral bulking procedure, a permanent material is injected into the urethral wall like a filler to “bulk up” the inner portion of the urethra and make it harder for urine to escape. This procedure is done outpatient under light sedation and takes less than 20 minutes. There is very little down time, and complications are rare. Some patients may experience temporary difficulty emptying the bladder that is typically managed with a bladder catheter overnight and resolves by the following day. Learn more about the Bulkamid procedure.
Mid-urethral Sling Placement
A mid-urethral sling is a strip of material that is placed beneath the urethra to help recreate the supporting structures that have become weak. The procedure is done on an outpatient basis with anesthesia. A small incision is made in the vagina to place the sling, and the procedure takes around 30 minutes. You will go home the same day. Although a small number of women have trouble voiding right after the procedure, most patients will go home without a catheter.
Most women have very little pain after sling placement. I advise light activity for 4-6 weeks after surgery, including no heavy lifting, no rigorous exercises and no intercourse. Learn more at VoicesforPFD.org.