Stress incontinence

Urinary incontinence is the unintentional loss of urine. Stress incontinence happens when physical movement or activity — such as coughing, laughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder, causing you to leak urine. Stress incontinence is not related to psychological stress.

Stress incontinence is different from urgency incontinence and overactive bladder (OAB). If you have urgency incontinence or OAB, your bladder muscle contracts, causing a sudden urge to urinate before you can get to the bathroom. Stress incontinence is much more common in women than in men.

If you have stress incontinence, you may feel embarrassed, isolate yourself, or limit your work and social life. You may also avoid physical and leisure activities. With treatment, you'll likely be able to manage stress incontinence and improve your overall well-being.

Symptoms

If you have stress incontinence, you may leak urine when you:

• Cough or sneeze
• Laugh
• Bend over
• Lift something heavy
• Exercise
• Have sex

You may not leak urine every time you do one of these things. But, any activity that puts pressure on your bladder can make involuntary urine loss more likely, particularly when your bladder is full.

When to see a doctor

Talk to your health care provider if your symptoms bother you or interfere with daily activities, such as your work, hobbies and social life.

Causes

Stress incontinence occurs when the muscles and other tissues that support the urethra (pelvic floor muscles) and the muscles that control the release of urine (urinary sphincter) weaken.

The bladder expands as it fills with urine. Typically, valve-like muscles in the urethra — the short tube that carries urine out of your body — stay closed as the bladder expands, preventing urine leakage until you reach a bathroom. But when those muscles weaken, anything that exerts force on the abdominal and pelvic muscles — sneezing, bending over, lifting or laughing hard, for instance — can put pressure on your bladder and cause urine leakage.

Your pelvic floor muscles and urinary sphincter may lose strength because of:

• Childbirth. In women, tissue or nerve damage during delivery of a child can weaken the pelvic floor muscles or the sphincter. Stress incontinence from this damage may begin soon after delivery or occur years later.
• Prostate surgery. In men, the surgical removal of the prostate gland to treat prostate cancer (prostatectomy) is the most common factor leading to stress incontinence. This procedure can weaken the sphincter, which lies directly below the prostate gland and encircles the urethra.

Contributing factors

Other factors that may worsen stress incontinence include:

• Illnesses that cause chronic coughing
• Obesity
• Smoking, which can cause frequent coughing
• High-impact activities, such as running and jumping, over many years

Risk factors

Factors that increase the risk of developing stress incontinence include:

• Age. Physical changes that occur as you age, such as the weakening of muscles, may make you more likely to develop stress incontinence. However, occasional stress incontinence can occur at any age.
• Type of childbirth delivery. Women who've had a vaginal delivery are more likely to develop urinary incontinence than women who've delivered via a cesarean section. Women who've had a forceps delivery to more rapidly deliver a healthy baby may also have a greater risk of stress incontinence. Women who've had a vacuum-assisted delivery don't appear to have a higher risk for stress incontinence.
• Body weight. People who are overweight or obese have a higher risk of stress incontinence. Excess weight increases pressure on the abdominal and pelvic organs.
• Previous pelvic surgery. Hysterectomy in women and surgery for prostate cancer in men can weaken the muscles that support the bladder and urethra, increasing the risk of stress incontinence.

Complications

Complications of stress incontinence may include:

• Emotional distress. If you experience stress incontinence with your daily activities, you may feel embarrassed and distressed by the condition. It can disrupt your work, social activities, relationships and even your sex life. Some people are embarrassed that they need pads or incontinence garments.
• Mixed urinary incontinence. Mixed incontinence is common and means that you have both stress incontinence and urgency incontinence — the unintentional loss of urine resulting from bladder muscle contractions (overactive bladder) that cause an urgent need to urinate.
• Skin rash or irritation. Skin that is constantly in contact with urine may get irritated or sore and can break down. This happens with severe incontinence if you don't take precautions, such as using moisture barriers or incontinence pads.

Diagnosis

During your visit, your health care provider looks for clues that may indicate contributing factors. Your appointment will likely include a:

• Medical history
• Physical exam, which may include a rectal exam and a pelvic exam in women
• Urine sample to test for infection, traces of blood or other abnormalities
• Brief neurological exam to identify any pelvic nerve problems
• Urinary stress test, in which the provider observes urine loss when you cough or bear down

Tests of bladder function

Common cases of urinary incontinence usually don't require additional tests. However, in some cases, your provider might order tests to assess how well your bladder, urethra and sphincter are functioning (urodynamic tests).

Bladder function tests may include:

• Measurements of post-void residual urine. Your provider may recommend this test if there's concern about your ability to empty your bladder completely, particularly if you are older, have had prior bladder surgery or have diabetes. This test can tell how well your bladder is functioning.

  A specialist uses an ultrasound scan, which translates sound waves into an image, to view how much urine is left in your bladder after you urinate. In some cases, a thin tube (catheter) is passed through the urethra and into your bladder. The catheter drains the remaining urine, which can then be measured.

• Measuring bladder pressures. Cystometry is a test that measures pressure in your bladder and in the surrounding region as your bladder fills. Your provider may recommend this test to check for stress incontinence if you have had a neurologic disease of the spinal cord.

  A catheter is used to fill your bladder slowly with warm fluid. As your bladder fills, you may be asked to cough or bear down to test for leaks. This procedure may be combined with a pressure-flow study, which tells how much pressure your bladder has to exert in order to empty completely.

• Creating images of the bladder as it functions. Video urodynamics is a test that uses imaging to create pictures of your bladder as it's filling and emptying. Warm fluid mixed with a dye that shows up on X-rays is gradually instilled in your bladder by a catheter while the images are recorded. When your bladder is full, the imaging continues as you urinate to empty your bladder.
• Cystoscopy. This test uses a scope that is inserted into the bladder to look for blockages or any abnormalities in the bladder and urethra. This procedure is usually completed in the office.

You and your provider should discuss the results of any tests and decide how they impact your treatment strategy.

Treatment

Your health care provider may recommend a combination of strategies to treat incontinence. If an underlying cause or contributing factor, such as a urinary tract infection, is identified, you'll also receive treatment for the condition.

Behavior therapies

Behavior therapies may help you eliminate or lessen episodes of stress incontinence. The treatments your doctor recommends may include:

• Pelvic floor muscle exercises. Your provider or physical therapist can help you learn how to do Kegel exercises to strengthen your pelvic floor muscles and urinary sphincter. Just like any other exercise routine, how well Kegel exercises work for you depends on whether you perform them regularly.

  A technique called biofeedback can be used along with Kegel exercises to make them more effective. Biofeedback involves the use of pressure sensors or electrical stimulation to reinforce the proper muscle contractions.

• Fluid consumption. Your provider may recommend how much and when you should consume fluids during the day and evening. However, don't limit what you drink so much that you become dehydrated.

  Your provider may also suggest that you avoid caffeinated, carbonated and alcoholic beverages, which may irritate and affect bladder function in some people. If you find that using fluid schedules and avoiding certain beverages significantly improve leakage, you'll have to decide whether making these changes in your diet are worth it.

• Healthy lifestyle changes. Quitting smoking, losing excess weight or treating a chronic cough will lessen your risk of stress incontinence and improve your symptoms.
• Bladder training. Your provider might recommend a schedule for toileting if you have mixed incontinence. More frequent voiding of the bladder may reduce the number or severity of urge incontinence episodes.

Medications

There are no approved medications to specifically treat stress incontinence in the United States. The antidepressant duloxetine (Cymbalta, Drizalma Sprinkle) is used for the treatment of stress incontinence in Europe, however.

Symptoms quickly return when the drug is stopped. Nausea is the most common side effect that makes people stop taking the medication.

Devices

Certain devices designed for women may help control stress incontinence, including:

• Vaginal pessary. A specialized urinary incontinence pessary, shaped like a ring with two bumps that sit on each side of the urethra, is fitted and put into place by your provider. It helps support your bladder base to prevent urine leakage during activity, especially if your bladder has dropped (prolapsed).

  This is a good choice if you wish to avoid surgery. A pessary will require routine removal and cleaning. Pessaries are used mostly in people who also have pelvic organ prolapse.

• Urethral inserts. This small tampon-like disposable device inserted into the urethra acts as a barrier to prevent leakage. It's usually used to prevent incontinence during a specific activity, but it may be worn throughout the day.

  Urethral inserts can be worn for up to eight hours a day. Urethral inserts are generally used only for heavy activity, such as repeated lifting, running or playing tennis.

Surgery

Surgical interventions to treat stress incontinence are designed to improve closure of the sphincter or support the bladder neck. Surgical options include:

• Sling procedure. This is the most common procedure performed in women with stress urinary incontinence. In this procedure, the surgeon uses the person's own tissue, synthetic material (mesh), or animal or donor tissue to create a sling or hammock that supports the urethra.

  Slings are also used for men with mild stress incontinence. The technique may ease symptoms of stress incontinence in some men.

• Injectable bulking agents. Synthetic polysaccharides or gels may be injected into tissues around the upper portion of the urethra. These materials bulk up the area around the urethra, improving the closing ability of the sphincter.
• Retropubic colposuspension. This surgical procedure uses sutures attached to ligaments along the pubic bone to lift and support tissues near the bladder neck and upper portion of the urethra. This surgery can be done laparoscopically or by an incision in the abdomen.
• Inflatable artificial sphincter. This surgically implanted device is used to treat men. A cuff, which fits around the upper portion of the urethra, replaces the function of the sphincter. Tubes connect the cuff to a pressure-regulating balloon in the pelvic region and a manually operated pump in the scrotum.

Lifestyle and home remedies

Healthy lifestyle practices can ease symptoms of stress incontinence. These include:

• Shed extra weight. If you're overweight — your body mass index (BMI) is 25 or higher — losing excess pounds can help reduce the overall pressure on your bladder and pelvic floor muscles. Moderate weight loss may markedly improve stress incontinence. Talk to your doctor for guidance on weight loss.
• Add fiber to your diet. If chronic constipation contributes to your urinary incontinence, keeping bowel movements soft and regular reduces the strain placed on your pelvic floor muscles. Try eating high-fiber foods — whole grains, legumes, fruits and vegetables — to relieve and prevent constipation.
• Avoid foods and beverages that can irritate your bladder. If eating chocolate or drinking coffee, tea (regular or decaf) or carbonated beverages seems to make you urinate and leak more frequently, try eliminating that drink, especially on days you really don't want to be bothered by leakage.
• Don't smoke. Smoking can lead to a severe chronic cough, which can aggravate the symptoms of stress incontinence. Smoking is also a factor in many cases of bladder cancer.

Coping and support

Treatments for stress incontinence can often substantially reduce, and possibly eliminate, urine leakage. Some people will still have urine leakage every now and then. Being prepared may help you cope.

Going out and about

Maintaining your connection with family, friends and co-workers can prevent feelings of isolation and depression that can accompany incontinence. Being prepared may help you feel more comfortable when you're out and about:

• Stock up on supplies. Take along sufficient incontinence pads or protective undergarments and possibly a change of clothes. Incontinence products are discreet and can be stowed in a roomy purse or a small backpack. Extra supplies and spare clothes can be kept in the trunk of your car or a backpack for use when needed.
• Scout out your destination. Familiarize yourself with the restrooms available at your destination. Choose seating that allows easy access to restrooms.
• Take good care of your skin. Prolonged contact with wet clothing can cause skin irritation or sores. Keep your skin dry by changing your garments when they're wet and applying a barrier cream if your skin is frequently wet.

Sexuality and incontinence

Leaking urine during sexual intercourse can be upsetting, but it doesn't necessarily have to get in the way of intimacy and enjoyment:

• Talk with your partner. As difficult as this may be initially, be upfront with your partner about your symptoms. A partner's understanding and willingness to accommodate your needs can make your symptoms much easier to handle.
• Empty your bladder beforehand. To reduce your chances of leakage, avoid drinking fluids for an hour or so before sex and empty your bladder before intimacy starts.
• Try a different position. Altering positions may make leakage less likely for you. For women, being on top generally gives better control of the pelvic muscles.
• Do your Kegel exercises. These exercises strengthen your pelvic floor muscles and reduce urine leakage.
• Be prepared. Having towels handy or using disposable pads on your bed may ease your worry and contain any leakage.

Seek help

Incontinence is not a normal part of aging. Treatments are usually available to cure or significantly reduce the effects of stress incontinence on your life.

Find a health care provider who's willing to work with you to determine the best way to treat your incontinence. Choosing the right treatments for you should be a partnership between you and your provider. Take time to discuss the pros and cons of the many treatment options with your provider.

Consider joining a support group. Support groups offer an opportunity to voice concerns and often provide motivation to maintain self-care strategies.

Organizations such as the National Association for Continence offer resources and information for people who have stress incontinence.

Preparing for an appointment

Your health care provider may have you fill out a questionnaire to make a preliminary assessment of your stress incontinence symptoms. You may also be asked to keep a bladder diary for a few days. In a bladder diary, you record when, how much and what kind of fluids you consume, as well as when and how much you urinate and when you experience incontinence episodes.

Your diary may reveal patterns that help your provider understand your symptoms and identify contributing factors. This may reduce the need for more invasive testing.

Specialized testing may require referral to a specialist in urinary disorders for men and women (urologist) or a specialist in urinary disorders in women (urogynecologist).

What you can do

To get the most from your visit to your health care provider, prepare in advance:

• Make a list of any symptoms you're experiencing. Include when urine leakage occurs.
• Make a list of any medications, herbs or vitamin supplements you take. Some over-the-counter supplements can irritate the urinary tract. Include doses and how often you take the medication.
• Have a family member or close friend accompany you. You may be given a lot of information at your visit, and it can be difficult to remember everything.
• Prepare a list of questions to ask your provider. List your most important questions first to be sure you cover those points.

For urinary incontinence, some basic questions to ask your provider include:

• Will my urinary incontinence get worse?
• Could pelvic floor exercises help me? How do I do them?
• How does my weight affect my condition?
• Could the medicines I take be aggravating my condition?
• What tests might I need to determine the cause of my incontinence?
• Will I need surgery?

Don't hesitate to ask other questions as they occur to you during your appointment.

What to expect from your doctor

Be prepared to answer questions from your provider. Questions your provider might ask include:

• How often do you leak urine?
• When you leak urine, is it a few drops or are your clothes soaked?
• Are there times when you know that you will leak?
• Do you leak urine when you exercise?
• Do you wake up during the night to urinate? How often?
• What's your typical daily fluid intake?
• Does anything seem to make your incontinence better? How about worse?
• What bothers you most about your urinary incontinence?
• Do you also have bowel leakage? How often? Does this cause you to restrict your activities?
• Does it seem as if there's something "falling out" of your pelvis or vagina?

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