Unintentional or involuntary loss of urine is known as Urinary Incontinence. Stress incontinence is a type of urinary incontinence where any exertional physical activity or movement leads to involuntary leakage of urine. This physical activity could be sneezing, coughing, running or lifting heavy objects, basically any activity which exerts pressure or stress on the bladder leading to urinary leakage. Stress incontinence occurs due to physical stress and is not related to emotional or psychological stress. Stress incontinence occurs more in women than men. It is different than urge incontinence, in which there is unintentional urine leakage due to the contraction of bladder muscle along with a sudden and strong urge to urinate.
Stress incontinence can cause embarrassment and restriction in social activities and can greatly impact a person’s quality of life. It is important to seek treatment for stress incontinence if it is affecting a person’s daily activities. Treatment helps in managing stress incontinence and in improving the quality of life.
Causes of Stress Incontinence
Pelvic floor muscles are the muscles, which support the tissues and muscles of the bladder along with regulating the release of urine. Weakening of pelvic floor muscles and urinary sphincter causes stress incontinence. As urine expands the bladder, the valve-like muscles in urethra stay closed during expansion of bladder and help in preventing leakage of urine until the patient reaches the restroom. Weakening of these valve like muscles causes urine leakage when any force is exerted on the pelvic and abdominal muscles. This force could be from physical activities/actions, such as bending over, sneezing, heavy lifting, laughing hard, coughing and other high impact activities, which puts pressure on the bladder resulting in urine leakage. Some of the causes which lead to weakening of pelvic floor muscles causing stress incontinence include:
- Childbirth in women leads to weakening in the muscles and function of the pelvic floor muscles and the sphincter. This happens due to nerve or tissue damage during delivery.
- Prostate surgery in men is the commonest cause for stress incontinence. Prostatectomy (surgical removal of the prostate gland) is done for treating prostate cancer. This surgery can result in weakening of the sphincter, which is located below the prostate gland.
Other contributing factors which can worsen stress incontinence are:
- Any illness which causes prolonged sneezing or coughing.
- Smoking also causes frequent coughing which causes stress incontinence.
- Excessive alcohol or caffeine intake.
- Excessive weight or obesity worsens stress incontinence.
- Hormonal deficiency also worsens stress incontinence.
- High-impact activities also cause stress incontinence.
Risk Factors for Stress Incontinence
- Ageing process causes weakening of the pelvic muscles thus making a person more vulnerable to stress incontinence.
- Delivery, especially a prolonged second stage of labor and multiple vaginal deliveries, increases the risk of stress incontinence. Having a forceps delivery also increases the risk for stress incontinence.
- Being overweight or obese also increases the risk of stress incontinence, as the pressure on the abdominal and pelvic organs is more. Losing weight can improve stress incontinence.
- Pelvic surgeries, such as hysterectomy in women and prostatectomy in men, alter the function and weaken the support of the urethra and bladder thus making a person more susceptible to developing stress incontinence.
Signs & Symptoms of Stress Incontinence
Stress incontinence is not a disease in itself, but a symptom of other underlying medical condition.
- Patient experiences urine leakage or stress incontinence when upon coughing, sneezing, laughing, standing up, lifting heavy objects etc.
- Patient also experiences urine leakage when exercising or having sex.
- If there is any infection, then patient can experience burning and pain in the pelvic region and during urination.
Investigations To Diagnose Stress Incontinence
- Medical history & physical exam.
- Neurological exam.
- Urodynamic testing.
- Urinary stress test.
- Post-void residual urine measurement.
- Bladder pressure measurement (cystometry).
Treatment for Stress Incontinence
Behavior Therapies for Stress Incontinence
Behavior therapies help in decreasing the episodes of stress incontinence and they comprise of:
- Kegel Exercise can be helpful for stress incontinence. Kegel exercises help in strengthening the urinary sphincter and pelvic floor muscles. The muscles of the pelvic floor need to be held for 5 seconds and then relaxed for 5 seconds. You can gradually increase the time to 10 seconds. Kegel exercises need to be done daily to see any improvement.
- Keeping a record of fluid intake and the time of fluid consumption helps in identifying the time and amount after which you experience stress incontinence. Patient should also avoid alcoholic and caffeinated beverages, as they act as diuretics and irritate the bladder. Avoiding dietary irritants and using fluid schedules can help in decreasing the urine leakage. Patient can change the pattern of fluid consumption and avoid irritants accordingly.
- Making lifestyle modifications, such as losing excess weight, quitting smoking, or treating that persistent cough helps greatly in reducing the stress incontinence.
- Bladder retraining, which is, making appointed or scheduled trips to the toilet, helps with incontinence symptoms especially in mixed incontinence.
Devices to Help Control Stress Incontinence
There are certain devices which help the female patients in controlling the stress incontinence symptoms, such as:
- Vaginal pessary is kept in the vagina to prevent urine leakage before any specific activity. This helps in supporting a prolapsed bladder. Pessaries are also beneficial in case of pelvic organ prolapse. However, they need to be routinely removed and cleaned.
- Urethral inserts are small tampon shaped disposable devices, which are inserted into the urethra. This acts as a barrier and prevents leakage and is worn before any specific activity and can also be worn throughout the day. However, they are advised only in rare cases.
Surgery to Treat Stress Incontinence
Surgery is done to support the bladder neck and to improve closure of the sphincter thus treating stress incontinence.
- Injectable bulking agents, such as synthetic gels or polysaccharides, can be injected into the surrounding tissues of the upper portion of the urethra. These materials help in bulking the region around the urethra and improve the closure of the sphincter. This is a relatively noninvasive procedure and is recommended before going for more invasive surgical options. However, the injections need to be taken on a regular basis.
- Sling procedure is the commonest procedure done in women suffering from stress urinary incontinence. In this procedure, synthetic material or a person’s own tissue or animal or donor tissue is used for creating a hammock or sling which supports the urethra. This procedure is also done for men with sphincteric leakage.
- Retropubic colposuspension is a surgical procedure which can be done either laparoscopically or via an incision in the abdomen. This procedure helps in lifting and supporting the tissues in the upper portion of the urethra and near the bladder neck. This procedure is often used along with procedures, which are used to treat a prolapsed bladder in women.
- Inflatable artificial sphincter is mostly used for men and rarely in women. This procedure comprises of surgically implanting a device in the upper portion of the urethra replacing the sphincter function.
Lifestyle Changes for Stress Incontinence
- Losing the extra weight helps in decreasing the overall pressure on the bladder as well as the pelvic floor muscles. Excess weight loss significantly improves the stress incontinence.
- Avoiding beverages and food items which irritate the bladder greatly help in any type of incontinence.
- Increasing the fiber intake, especially if you suffer from chronic constipation, help in keeping the bowel movements regular and soft and reduces the strain exerted on the pelvic floor muscles.
- Quitting smoking also helps with stress incontinence, as smoking causes severe and persistent cough, which exacerbates the symptoms of stress incontinence. Smoking also decreases the oxygen-carrying capacity of a person, which in turn increases the risk of an overactive bladder. Smoking can also lead to bladder cancer, so it is best to quit smoking for bladder health.