Stress Incontinence

Loss of urine control, or urinary incontinence, affects more than 13 million people in the U.S., most of them women. Although it is more common with age, incontinence can afflict even women in their 20s and 30s. Pregnancy and childbirth, menopause and the structure of the female urinary tract account for the difference in incidence between men and women.

Types

There are several types of incontinence. The two most common forms are stress incontinence, which can be caused by something as ordinary as a cough or sneeze, and urge incontinence, which occurs without notice or stimulus. Some patients have a combination of both. Stress incontinence is the most common form in women. Coughing, sneezing or exercising puts pressure on the bladder and causes the individual to leak urine.

Signs and Symptoms

• Leaking urine when one coughs, sneezes, or laughs.
• Having an uncomfortably strong need to urinate.
  • Leaking before you reach the toilet.
• Urinate more than 8 times a day.
• Getting up more than 2 times a night to urinate.
• Having wet the bed in the past year.
• Feeling a need to urinate when nervous or under stress.
• Leaking during or after sexual intercourse.
• Having had multiple bladder, urine, or kidney infections.
• Being troubled by pain or discomfort when urinating
• Having blood in one's urine.
• Finding it hard to begin urinating.
• Having a slow urinary stream.
• After urinating, feeling that one's bladder is still full.
• Having noticed a bulge in the vaginal area when bathing?

Causes

The bladder is like the body’s water tank, collecting and storing urine. Attached to this balloon-shaped tank is a “hose” called the urethra, through which urine exits the body. Doughnut-shaped sphincter muscles wrap around the urethra like a rubber band, keeping it pinched tight until it is time to urinate. In addition, a set of muscles called the pelvic floor muscles surround the sphincters to hold everything in place. As women grow older, a combination of factors, including stretching during childbirth and the loss of estrogen at menopause, can continue to weaken the muscles, causing everything inside to sag. The bladder moves downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. Stress incontinence also occurs if the sphincter muscles that surround the urethra and allow it to open or close become stiff over time and eventually, usually after menopause, fail to stay closed properly.

Treatment

The overwhelming majority of those with incontinence can be improved or cured. There are several treatment options, both surgical and nonsurgical, that can restore a woman’s quality of life. Typically the least invasive treatment options are considered first.

If a patient only has a problem when she goes for a walk or plays tennis, physicians often recommend she try inserting a tampon before such activities. In some women, the tampon provides enough support for the bladder to take care of the problem. In many others, it may not.

Nonsurgical approaches

Many women can benefit from Kegel exercises, which strengthen the pelvic floor muscles and help keep the pelvic organs in place, reducing the pressure on the urethra. To be effective, it’s important that women learn the correct way to do Kegel exercises. It is not always easy to isolate the right muscles and contract them at just the right time to prevent urine leakage. Studies have shown 30 percent of women contract the wrong muscle after they’ve received verbal instructions in Kegel exercises. Those who are trained by physical therapists in the proper technique have the most success with this method. Teaching patients by giving them visual or auditory biofeedback when they’re contracting the right muscles is very successful.

An office procedure using collagen injections underneath the urethra to make the opening smaller can be a good temporary fix for patients whose health problems may make them poor candidates for surgery, but the effects are not long-lasting.

Surgical options

Open retropubic colposuspension is often considered the best treatment option. It requires a two-day hospital stay and four to six weeks to recover. Patients report a dramatic difference a couple of days after surgery. (See the Clinical:Stress Incontinence Article for more details on the study)

The same procedure can be done with a laparoscope, using smaller incisions. This less invasive approach makes it possible for patients to recover more quickly than with open surgery, but there is a 33 percent failure rate with this technique after three years.

Sling procedures have been practiced for more than 50 years. They involve placing a sling made of tissue from the patient or an animal or plastic around the neck of the bladder to lift it back into its normal position. The sling is placed around the urethra and attached to the abdominal wall. Two to three days of hospitalization are required for this procedure.

Needle suspension procedures involve passing a needle through a small incision in the abdomen through tissue surrounding the bladder neck and urethra. The tissue is then pulled upward and attached with surgical thread to the abdominal wall. Recovery with needle procedures is quicker than open surgeries, but the long-term failure rate is quite high.

There is a new treatment, which was developed about six years ago, called the tension-free vaginal tape procedure. A surgeon makes three small incisions and passes synthetic mesh tape through the incision and through the middle part of the urethra to return it to its normal position. No sutures are required, and the procedure can usually be done under local anesthesia. A three-year study in Sweden, where the procedure was developed, shows it works 90 percent of the time, but there is no long-term data demonstrating its long-term success. I often perform it on my elderly patients for whom a long-term solution is not as important as a quick recovery time.

Chances of Developing Stress Incontinence

Risk factors

Factors that may contribute to the problem include childbirth (where tissues, muscles, and nerves supporting the urethra may be damaged), menopause, obesity, hysterectomy (which increases the risk of incontinence by 30-40%), and medical illness (diabetes, lung disease, stroke).

Epidemiology

Many people think incontinence is an uncommon and unusual problem that affects only a limited number of very elderly or disabled women, but in the U.S. alone, it is estimated that there are between 10 and 20 million women suffering from the involuntary loss of urine. The large baby boomer population is now moving through the menopausal transition when incontinence often becomes worse, and consequently the number of affected women will only increase. Although incontinence may occur much earlier than menopause, it often worsens during this phase of a woman's life.

About 20 percent of women have temporary incontinence problems right after childbirth. Physicians long thought that injury during vaginal deliveries was the usual cause, but a the Yale-New Haven Hospital’s section of Urogynecology and Reconstructive Pelvic Surgery conducted a study comparing pelvic organ prolapse in women who delivered vaginally versus those who delivered via Caesarean section and found similar rates among women who experienced the first stage of active labor. Fifty-two percent of women who have had at least one child experience a drop in their pelvic organs, but we don’t understand at this point why some of them go on to develop incontinence and some don’t. Incontinence is an equal opportunity condition. Women of all ethnic backgrounds are equally vulnerable.

After age 50, one in two women will have some degree of urinary incontinence and yet few women talk about it, either with each other or with their doctors. Many of them are too embarrassed to mention it even to their friends, and just go about altering their lives so as to avoid embarrassment. Urinary incontinence can be devastating psychologically as well as emotionally and physically to a woman. Many women leak urine with just about any kind of exercise or exertion. A cough, a hiccup, a tennis match or a hearty laugh can result in urine leakage.