Stress Urinary Incontinence

What is Stress Urinary Incontinence?

Urinary incontinence refers to the inability to control the release of urine, and it inevitably has a significant impact on a patient’s everyday life worldwide. It also costs healthcare systems a great deal of money. In women, the experience of urinary incontinence at some point in their lives is above 60%, with those who have had children and older women being more affected. There are several types of urinary incontinence, including stress, urge, overflow, and mixed incontinence, each with specific and sometimes multiple causes.

Stress urinary incontinence is a condition where you can lose control of your bladder during physical activities that put pressure on your abdomen, such as heavy lifting, sneezing, coughing, laughing, or straining. It results from a mix of physical and internal issues that interfere with the controls that normally prevent urinary leaks. Risks that cannot be changed include being a woman and being of White race, whereas risks that can be changed or avoided include smoking, obesity, and chronic constipation.

In women, things like pregnancy, having multiple vaginal deliveries, menopause, being overweight, and having pelvic surgeries like a hysterectomy, may contribute to stress urinary incontinence. Also, pelvic organ prolapse, which is common after menopause or childbirth, often goes hand-in-hand with stress incontinence. Stress incontinence is much less common in men, and usually happens after prostate surgeries.

A study conducted from 2005 to 2016 with over 15,000 women in the United States found that over half had experienced some degree of incontinence, with about 25% experiencing only stress urinary incontinence. Though it is not a life-threatening condition, urinary incontinence can greatly affect the elderly population, often requiring surgery when non-surgical options don’t work. The costs of managing stress incontinence in the United States have recently surpassed $13 billion per year.

Treatment methods for urinary incontiness include lifestyle changes, bladder training, Kegel exercises, physical therapy, biofeedback, electrostimulation, medication, pessaries, bulking agents for the urethra, slings, and a range of surgical operations including artificial sphincters.

This overview simplifies the diagnosis and numerous treatment choices available to patients with stress urinary incontinence.

What Causes Stress Urinary Incontinence?

Stress urinary incontinence is a condition where you experience urine leakage when pressure increases in your bladder, such as when you laugh, cough, or sneeze. This happens because the tube that carries urine out of the body (the urethra) is unable to stay closed, often due to damage to the muscles that help control urination.

There can be many factors contributing to stress urinary incontinence. For example, the muscles and connective tissues that support the pelvis and maintain continence can weaken. This weakening can be due to a range of conditions or behaviors like connective tissue disorders, chronic cough, obesity, trauma to the pelvic floor, childbirth, pelvic or vaginal surgery, certain symptoms of menopause, chronic constipation, heavy lifting, smoking, and more. In women, this is the most common cause of stress incontinence.

Another reason for stress urinary incontinence is what’s known as intrinsic sphincter deficiency. This can occur if the muscles that control urine flow are damaged or dysfunctional due to pelvic surgery, disorders affecting the nerves and spine, trauma, certain types of fractures, nerve injury from abdominal surgery, radiation therapy of the pelvis, or complications of surgery on the urinary tract (like prostate surgery). This type of incontinence can affect both men and women but is more commonly found in men, and it can cause continuous leakage of urine.

Vaginal atrophy, or thinning and drying of the vaginal walls, is most commonly seen in women undergoing menopause, but it can affect women of any age who have a decrease in estrogen to the urogenital tissues. For example, younger women may experience this during breastfeeding, after childbirth, or due to conditions like hypothalamic amenorrhea or the use of antiestrogenic drugs. However, it’s essential to know that not all women with vaginal atrophy will show symptoms.

Recent studies have also found that exposure to heavy metals such as lead and cadmium can increase the risk of stress incontinence, particularly in younger and middle-aged women. Additionally, higher levels of good cholesterol (known as high-density lipoprotein or HDL) were linked to a lower risk of developing stress urinary incontinence. Therefore, maintaining healthy HDL levels might be a preventative measure for this condition in the future.

Risk Factors and Frequency for Stress Urinary Incontinence

Urinary incontinence, or the loss of bladder control, is a common issue among women. In fact, about 62% of women will experience this problem to some degree, with 37.5% of these cases being stress urinary incontinence, and another 31% being a mixed type. Stress urinary incontinence is particularly common among older women in nursing homes, affecting up to 77% of them.

• Among those with stress urinary incontinence, 77% find it bothersome.
• About 28.8% experience moderate to severe symptoms.
• 22% describe their symptoms as severe.

In Europe, around 14.5% of those aged 30 to 60 faced this problem in 2022. In Romania, the problem is even more prevalent, with at least 18% of women affected — but this figure may even be higher due to underreporting. Similarly, 18.9% of adult women in China deal with stress urinary incontinence.

The risk of this condition increases with age, especially among women over 70, and is more common following menopause, in people who are obese, and in those who have given birth vaginally. In fact, having stress incontinence during pregnancy increases the risk of having it again 12 years after giving birth. Other factors that increase the likelihood of stress urinary incontinence include anxiety, depression, being functionally dependent, and being a non-Hispanic White woman.

While this is a deeply impactful issue, only 60% of women with incontinence symptoms seek treatment. For men, urge incontinence, often related to benign prostatic hyperplasia, or enlarged prostate, is more common. However, some men do experience stress incontinence, usually after surgery. Despite this, men are less likely to seek help due to embarrassment and the misconception that urinary leakage is only a problem for women.

Signs and Symptoms of Stress Urinary Incontinence

To diagnose stress urinary incontinence, a careful study of the patient’s health history and a thorough physical examination are needed. Stress urinary incontinence is when a patient leaks urine during activities that put pressure on the abdomen like laughing, sneezing, or exercising. The doctor needs to learn about the frequency, progression, and impact of this condition on the patient’s everyday life, including how it affects their social interactions and quality of life. This helps determine if the patient needs more aggressive treatment. The patient should be asked to provide details about:

• Fluid intake
• Past and current medical conditions, including urinary infections, diabetes, any surgeries involving the urinary system, any trauma related to childbirth, pelvic radiation, and disorders of the nervous system or spine
• Medications they are on
• Menopause status
• Getting up at night to urinate (nocturia)
• Psychological stress
• Situations or events that cause urine leakage
• Timing in relation to these events and urine leakage
• Type and quantity of protective products used daily, such as pads, tampons, or diapers
• Urination pattern

The patient should also keep a diary recording instances of urine leakage, the time they occur, fluid intake, and any noticeable patterns. Ideally, this diary should be kept for three days, but even a one-day diary can be useful. This helps in better understanding and treating the condition.

During the physical examination, the doctor looks for other potential causes of incontinence and assesses the patient’s overall health condition. They’ll also note any physical factors that could be affecting the condition, such as chronic lung disease, obesity, or any masses in the abdomen. A neurological examination is also important during this assessment.

The pelvic examination should be conducted when the patient is standing and lying down, and both when the bladder is full and empty. During the pelvic exam, the practitioner might discover pelvic relaxation, such as a cystocele, rectocele, or uterine prolapse. In postmenopausal women, it’s critical to evaluate the estrogen status of the vagina and bladder as an estrogen deficiency might contribute to incontinence. A cough stress test may also be conducted to subjectively demonstrate stress incontinence.

The extent of uterine and bladder prolapse is judged by using a pelvic organ prolapse quantification system. The presence of severe pelvic organ prolapse can complicate the situation and possibly reduce the apparent severity of the patient’s stress incontinence. In cases of advanced-stage cystoceles, stress incontinence comes in a ratio of 3:1:1 for cases with overt, hidden, and undemonstrable symptoms, respectively.

Testing for Stress Urinary Incontinence

Initial evaluation of any form of incontinence should include the following elements:

– A 24-hour voiding diary (ideally, a 3-day diary should be used, but it’s easier for patients to keep a record for 1 day).
– A detailed history, especially regarding urinary and genital health, previous surgeries, childbirth, and bladder habits.
– A physical examination, including demonstrating the stress urinary incontinence while lying down and standing up.
– For females, a thorough and detailed pelvic examination to test for abnormal movement of the urethra (Q-tip test).
– The measurement of the amount of urine left in the bladder after urinating.
– Urinalysis to check for urinary tract infections or underlying kidney disease, such as stones or tumors. There may or may not be need for urine culture in this case.
– For uncomplicated stress urinary incontinence, urodynamic testing is usually not necessary at the early stages.

Urodynamic testing or video urodynamics studies should be considered for patients with more complex incontinence symptoms. This includes significant other health conditions, people over 60, unpredictable leakage, failed previous incontinence treatment, radiation therapy for the pelvic area, uncertainty around diagnosis, or a history of radical pelvic surgery. Testing should include the measurement of leak point pressure and maximum closing pressure of the urethra.

Urodynamic testing and imaging are not usually necessary before surgery in uncomplicated cases, as they are unlikely to change the treatment results. However, in more complex cases or selected cases of mixed incontinence, they are typically carried out before surgery.

Blood tests might be needed to rule out diabetes or other systemic disorders. A cystoscopy, which is a procedure to see inside your urethra and bladder, can sometimes be used to rule out intrinsic lesions of the bladder lining and urethra.

The Q-tip test is often done in the office to check for abnormal movement of the urethra in females. A positive result can indicate pelvic relaxation related to stress urinary incontinence. A negative result can indicate that the leakage might be for reasons other than abnormal urethral movement and pelvic relaxation.

A transperineal ultrasound could provide an alternative, non-invasive method to the Q-tip test. The bladder neck rest-stress distance on ultrasound with a cut-off value of 13.3 mm aligns well with the Q-tip test results for diagnosing urethral hypermobility in women with urinary stress incontinence.

Less experienced doctors may refer the patient to a urogynecologist or urologist for medical or surgical treatment. Referral to a specialist is especially suggested for patients with irregular pelvic anatomy, co-existing neurological conditions, diagnostic uncertainty, failed medical therapy, pelvic radiation therapy, past incontinence or significant pelvic surgery, genital organ prolapse, recurrent urinary tract infections, significant overactivity of the bladder, unexplainable blood in the urine, or unusually severe incontinence.

Treatment Options for Stress Urinary Incontinence

Stress urinary incontinence can be distressing and, for treatment, there are a variety of choices including behavioral changes, mechanical devices, medications, and surgeries. Regardless of the treatment chosen, patients should be advised on lifestyle changes such as losing weight, quitting smoking, dealing with constipation, and avoiding foods and drinks, like caffeine, alcohol, citrus fruits, chocolate, and tomatoes, which can irritate the bladder.

Behavioral changes can be a big help. One of these is training the bladder to urinate on a schedule, which can help it hold more for longer periods of time. A type of exercise known as “Kegel exercises” can also help to strengthen the muscles in the pelvic floor. The difficulty lies in keeping patients motivated and consistent in their exercising. These exercises have proven helpful especially when combined with bladder training. There’s also a technique of using visual or audio signals (known as biofeedback) to guide correct muscle contractions. Additionally, there is electrostimulation, which uses acupuncture needles and electrical stimulation to make the pelvic floor muscles contract and ease the symptoms of stress urinary incontinence.

Mechanical devices are another option. One such device is the pessary, a device inserted into the vagina, especially useful in cases where surgery might not be possible or the patient has a history of failures with previous treatments. A proper fitting is critical to getting the benefits of a pessary without discomfort. Similarly, bladder vaginal supports drawn comparisons to tampons, but work by stabilizing the urethra to prevent leaks during activities like coughing or sneezing.

Medications like anticholinergics which relax the bladder, are used often. Another medication, Duloxetine, works by affecting neurotransmitters at the pudendal nerve and can noticeably reduce stress incontinence episodes. However, it could come with side effects like nausea and vertigo. Estrogen is used topically in the vaginal area increasing blood flow to the urethra and enhancing the sensitivity of alpha-adrenergic receptors. Other medication includes tricyclic antidepressants that help in constricting the urethra.

Surgery is another option, with the primary goals being to support the ligaments around the urethra and the connective tissue mid-way along the urethra. This can be done either with abdominal or vaginal procedures, or with devices like urethral slings. There isn’t one type of surgery that works for all patients – it has to be tailored to each individual’s needs. Sometimes, a hybrid approach is used, such as when prolapse and stress urinary incontinence occur together.

For men, options include male urinary slings, dual-balloon implant devices, and artificial urinary sphincters, all of which seek to limit stress incontinence. These can range from less-invasive outpatient procedures to full surgery, depending on the severity of the incontinence and the patient’s comfort with more invasive procedures.

In conclusion, a mix of behavioral, mechanical, pharmaceutical, and surgical treatments exist for stress urinary incontinence. Medical professionals will work with you on choosing the appropriate treatment for your symptoms.

What else can Stress Urinary Incontinence be?

If a patient shows signs of stress urinary incontinence, or sudden urine leakage due to stress, it’s critical to consider other possible reasons this might be happening. The aim is to ensure the right diagnosis is made and appropriate treatment provided. A comprehensive patient history and detailed physical exam are key steps in ruling out other potential reasons. If the diagnosis isn’t clear or seems complex, urodynamic testing, a type of urine flow test, may be advised.

Below is a list of conditions that could also be causing symptoms similar to those of stress urinary incontinence:

• Bladder stones
• Bladder tumors
• Born with conditions like ectopic ureter and epispadias
• Fistulas or abnormal connections developed after surgery or radiation
• Functional incontinence (no specific physical cause)
• Problems due to menopause or other causes of estrogen deficiency (genitourinary syndrome)
• A condition called interstitial cystitis
• Neurologic causes:
• Stroke
• Multiple sclerosis
• Parkinson disease
• Senile dementia
• Meningomyelocele
• Spinal injury
• Pelvic masses pressing the bladder
• Prolapse or organs slipping down from their normal position
• Pharmacologic causes including certain drugs like diuretics, parasympathomimetics, antidepressants, and phenothiazines
• Post-infection scarring (fibrosis)
• Radiation
• Systemic medical causes:
• Hypothyroidism
• Diabetes
• Depression
• Urinary tract infections, such as bacterial, chlamydial or tuberculosis

There are also three other types of urinary incontinence to be aware of:

• Mixed incontinence: involuntary loss of urine due to both urge and stress incontinence.
• Overflow incontinence: continuous urinary leakage or dribbling due to urinary retention.
• Urge incontinence: involuntary loss of urine due to urgency or a sudden, strong desire to urinate.

What to expect with Stress Urinary Incontinence

Stress urinary incontinence, which causes unintentional urine leaks during stressful activities, can greatly affect a person’s life. While treatments aim to improve life quality, complete recovery might not always be possible. It’s common to use different types of treatment like behavior changes, medication, and at times, surgery. Even a small improvement in incontinence symptoms can sometimes make a patient happy, mainly if it helps avoid surgery.

The chances of getting better from stress incontinence can change based on factors such as the nature and severity of the condition, effectiveness of treatment, age, and general health. With the right treatment strategy, many individuals experience significant improvement in their symptoms. Simple measures like pelvic floor muscle exercises (also known as Kegels), behavioral changes, and shifts in lifestyle often have positive results, particularly when started early.

Modifying your lifestyle alone can be beneficial. For instance, losing just 8% of weight through exercise resulted in nearly a 50% reduction in the frequency of incontinence episodes for some people. Additionally, pelvic floor exercises led to a complete recovery for 58.8% of patients after 12 months.

Research into the effects of pelvic floor exercise on sexual function showed that while it effectively treated stress incontinence, it didn’t improve sexual function. However, vaginal pessaries (a device inserted into the vagina to support its walls) helped improve symptoms for 33% of patients.

The use of estrogen in treating stress urinary incontinence remains a topic of debate. Topical estrogen (applied directly to the skin) might help increase blood flow to the urethral area and thicken the vaginal tissue if vaginal surgery is planned. Using anticholinergics, a type of medication, led to 49% improvement in controlling symptoms.

In cases where simpler measures are unsuccessful, surgery can improve continence and provide long-term relief. The success rate of surgical treatment is about 84%, irrespective of the method used. Moreover, the quality of life often improves after the surgery for patients with stress urinary incontinence, with or without the presence of pelvic organ prolapse, which is a condition where organs slip down from their normal position in the body.

Several studies compare different surgical procedures’ effectiveness, but none prove definitively superior. One trial found no success rate difference between two surgical interventions, Burch colposuspension and the retropubic mid-urethral sling, after 6 months, and even after five years.

One type of treatment, an artificial urinary sphincter implant, seemed to work better than slings for males with moderate stress incontinence, but it’s crucial to choose the right patients. No significant differences were found in the risk of complications between the two procedures.

Another study compared results from two other procedures, the MPP and the MMK, finding similar results. In this study, 84% of MPP patients were cured compared to 86.6% of MMK patients. Additionally, urethral bulking injections led to complete recovery between 24.8% and 36.9% at the 12-month mark.

Remember, underlying health conditions, other illnesses, and commitment to treatment and lifestyle changes can all impact the prognosis of stress urinary incontinence. Regular follow-up and ongoing management are critical. It’s the keen attention to these details that helps in monitoring progress, adjusting treatment plans when needed, and making the best possible long-term outcomes. Sometimes, surgery might not work if not all causes of incontinence have been properly evaluated, or risk factors like obesity and smoking have not been addressed.

Possible Complications When Diagnosed with Stress Urinary Incontinence

Stress urinary incontinence, or the unintentional leaking of urine, can have multiple impacts that significantly reduce a person’s quality of life. Physically, the regular leakage can lead to issues like skin irritation, rashes, and infections in the area around the genitals, causing discomfort and additional health problems. From a social and mental perspective, major instances of stress urinary incontinence can lead to feelings of public humiliation, nervousness, and avoidance of social activities out of fear of triggering an episode. This withdrawal can cause feelings of isolation, depression, and an overall reduced sense of wellness. Additionally, the financial implications of constant purchases of incontinence products, medical treatments, and possible reduction in work output can place a significant burden on an individual’s finances.

Certain medications can also have side effects. The most commonly noticed adverse side effects of anticholinergics, a type of medication, are dry mouth and constipation. Anticholinergics can also worsen existing heart rhythm issues and a specific kind of glaucoma.

Surgical interventions can come with their own complications including issues with emptying the bladder and holding in urine, urinary tract infections, pain during intercourse after the operation, damage to the mesh support system used in the operation, pelvic organ prolapse, device failure or movement, and ongoing or returning urinary incontinence. Experience of significant bleeding or injury to the digestive or urinary system, such as punctures in the bowel or bladder, can also occur as results of surgery.

In some scenarios, the complications resulting from stress incontinence can even lead to more severe kidney-related issues. This highlights the importance of timely and effective treatment of stress incontinence to prevent these complications and improve a person’s overall health and quality of life.

Possible Problems:

• Skin irritation, rashes, and infections
• Public embarrassment and social withdrawal
• Anxiety and depression
• Financial strain
• Side effects from medication
• Complications after surgery
• Potential kidney issues

Preventing Stress Urinary Incontinence

Preventing and teaching people about stress incontinence – or the inability to control urination – is incredibly important. When people come in for their yearly health check-up or women’s health exam, doctors should check for any signs of incontinence. Men, too, especially after a prostate surgery, should be asked about any problems with involuntary urination.

By telling people about ways to reduce their risk of stress incontinence, and things they can do to decrease its impact, we can significantly lower the number of people who experience the issue. You can do practical things like maintain a healthy weight, exercise regularly and avoid things like caffeine and alcohol, which can irritate your bladder. Another suggestion is to regularly exercise your pelvic floor and core muscles. Having strong pelvic and abdominal muscles can help prevent and manage incontinence.

Providing guidance on proper lifting methods and managing health conditions like constipation, obesity, smoking, and lung issues can also help to lower the risk of developing stress incontinence. When you’re given clear, well-explained tips on preventing incontinence, it allows you to take control of your health and improve your overall quality of life. By having open conversations and combating any false beliefs or shame about stress incontinence, we can support each other to better prevent and manage the issue.

You should be well-informed about all available treatment options like conservative, non-invasive treatments, and surgeries. It’s crucial to know that while surgery produces the highest cure rate for stress incontinence, improvements can still be made with behavioral changes or medication. Some people may prefer to manage stress incontinence without surgery, especially in risky scenarios, believing it to be good enough. Accepting these alternative treatments can increase people’s motivation to continue these therapies.

You can find more information regarding stress incontinence on websites like the American College of Obstetricians and Gynecologists, the American Urogynecologic Society, the Urology Care Foundation, the American Urological Association, and Advancing Female Pelvic Medicine and Reconstructive Surgery. You can also find helpful resources at self-help groups and incontinence organizations, such as the National Association for Continence and the Incontinence Support Center.