Stress Incontinence

Saketha has had two children. Recently she has noticed that when she sneezes or coughs, she loses a few drops of urine. Saketha has stress incontinence. Stress incontinence, which is the most common type of urinary incontinence in younger women, occurs when a woman coughs, laughs, or sneezes. As the condition gets worse, she may lose urine when she walks, runs, or does aerobics. This kind of leakage occurs when the tissues that support the bladder or the muscles of the urethra (urinary passage) get weak.

Tarangini is in her early sixties. She finds that she has to rush to the bathroom when she gets the urge to pass urine and even loses a few drops of urine before she can reach the bathroom. She has urge incontinence. This is sometimes called overactive bladder. It occurs if the muscles of the bladder are too active and contract too often. This leads to leakage of urine. This can also occur when there are problems with the nerves that send signals to the bladder.

What is urinary incontinence?

Urinary incontinence is the involuntary leakage of urine. It is more common in women than in men. At some time or the other in their lives, many women will leak small amounts of urine. These leaks can occur with certain physical activities or with other stress, such as coughing, laughing or sneezing. Some women may lose urine when they hear the sound of running water or when their hands are in water. Some women feel the sudden urge to urinate and cannot control it. Others leak urine only when they are pregnant. When leaks become frequent or severe enough to be a problem, it is called urinary incontinence or loss of bladder control. Loss of bladder control is a common problem among women and there are several treatment options available. Urinary incontinence (leakage) can often be treated with success.

Unfortunately, women tend not to seek help from their doctors for this problem. More than one half of women who have symptoms do not seek medical care. They feel embarrassed or ashamed and try to hide the problem. Many women are depressed about it and avoid social occasions or long periods away from home.

Types of urinary incontinence

There are five types of urinary incontinence: stress incontinence, urge incontinence, mixed incontinence, overflow incontinence and functional incontinence. Stress and urge incontinence have already been described above. Mixed incontinence occurs when a woman has both stress and urge symptoms. This combination may cause more urine to leak than either type alone would. Overflow incontinence occurs when the bladder does not empty completely and keeps filling up. When it is overfilled, small quantities of urine will periodically leak. This is often associated with damage to the nerves supplying the bladder. Functional incontinence occurs when other health problems keep a woman from getting to the toilet in time. Conditions that cause it include arthritis, stroke and problems with mobility (inability to move or walk fast).

What are the causes of urinary incontinence?

Urinary tract infection

Commonly in women, loss of bladder control may be caused by an infection of the urinary tract. When there is a bladder infection, the woman may suffer severe pain when she passes urine, and have the urge to pass urine very frequently. Infections are easily treated and the symptoms of leakage will resolve with appropriate antibiotics.

Problems of pelvic support

The uterus, the bladder and the other organs in the lowest part of the abdomen (pelvis) are held in place by supportive tissues and muscles. These tissues are stretched or weakened by pregnancy, childbirth, and ageing. This ultimately leads to sagging of the muscles supporting the pelvic organs. The muscles around the bladder and the urinary passage (urethra) are, therefore, unable to hold back urine.

Neuromuscular disorders

In conditions like severe diabetes, stroke, or multiple sclerosis, the nerve supply to the bladder is affected. The signals from the brain and spinal cord do not connect properly with the bladder and urethra. The woman does not sense that her bladder is full and the urine will overflow when the bladder gets overfilled.

Diagnosis & Evaluation

The most important thing that the doctor will do to establish the diagnosis of urinary incontinence is to take a thorough history. She will ask you specific questions about how often you pass urine (frequency), whether you have to rush to the bathroom the moment you feel like passing urine (urgency), whether you lose a few drops or a larger quantity of urine when you cough, sneeze or laugh (stress incontinence). She will ask you about other medical problems you may have which might have an effect on the leaking of urine. Women with chronic cough may need to get their cough taken care of before embarking on the tests and treatment.

What are the tests that are done?

Your doctor will do a pelvic exam to make sure that there are no specific physical reasons for the incontinence. A uterus, which is significantly enlarged by fibroids, may press on the bladder and lead to loss of urine.

You will be asked to cough while being examined. This requires you to have a full bladder. If you lose urine when you cough or bear down, then stress incontinence is diagnosed.

If your doctor is not able to establish what kind of incontinence you have, she may ask you to undergo urodynamic testing. During urodynamic testing, your bladder is filled up with water and tests are done to determine the pressure inside the bladder and the volume of urine the bladder can hold. This test can help pinpoint the best treatment that would ease your symptoms.

What are the treatment options?

Treatment depends on the type of incontinence you have.

Behavioral therapy is particularly useful in hyperactive (or overactive) bladder. With a hyperactive bladder, a woman has the urge to pass urine very frequently and will lose urine if she cannot get to a bathroom fast enough. In this condition, the muscles that contract the bladder are hyperactive. You will be asked to pass urine at set times, slowly increasing the intervals, so that your bladder can be trained to respond to you instead of you becoming a slave to your bladder.

Medications may need to be used if behavioral therapy fails. Drugs that help control muscle spasms can help prevent leaks. Some help relax a bladder that is too active. One of the common side effects of these medications is dryness of the mouth.

With mild stress incontinence, you will be asked to learn Kegel exercises. Kegel exercises tone your pelvic muscles. They strengthen the muscles around the openings of the urethra, the vagina and the rectum. This is how it is done:

When you are urinating, tighten the muscles to stop the flow of urine. Once you have learnt the sensation of tightening the muscles, you can do the exercise after you have emptied your bladder. Squeeze the muscles that you use to stop the flow of urine. Hold for up to 10 seconds, then release. Do this 10-20 times in a row, at least 3 times a day. Be careful not to squeeze the muscles of the leg, buttock, or abdomen. Do these exercises on a regular basis. After 6-12 weeks, you should find that the amount of urine you leak has decreased significantly.

Some other lifestyle changes which help reduce stress incontinence are: losing weight, avoiding constipation, avoiding very heavy lifting (that cause urine leaks), drinking less caffeine (coffee and tea) and getting treatment for chronic cough.

Surgery for urinary incontinence

If lifestyle modification and Kegel exercises do not improve the symptoms of stress incontinence, surgery may be resorted to.

Bladder neck suspension is a procedure designed to provide support to the urethra and bladder neck, which is the area where the bladder connects to the urethra. For this procedure, an incision is made in the lower abdomen. Through this incision, stitches are placed in the tissue near the bladder neck. This is called the Burch procedure which has, over the years, proved to be the most successful surgical treatment for stress urinary incontinence.

Sling procedures use a pelvic sling, like the tension-free vaginal tape (TVT), around the bladder neck. The sling provides support to keep the urethra closed, especially during coughing or sneezing. The placement of this tape does not require major surgery.

Dr.Ravindra Varma

Dr. G.Ravindra Varma M.S.,M.Ch.,(Uro) Bombay
D.N.B.(Genito_Urinary Surgery)
Fellow Urology (Singapore)

Consultant
Urologist & Andrologist