Stress Urinary Incontinence

Stress urinary incontinence is the most common type of incontinence among women, including women under the age of 60. The Urology Care Foundation estimates that one in three women will experience the condition at some point in their lives.

It affects women more often than men because pregnancy and childbirth weaken the pelvic muscles. Because women feel embarrassed by the symptoms, SUI is underreported and underdiagnosed.

American women spend more than $20 billion a year on expenses associated with SUI. Most of it is spent on incontinence pads, diapers, dry cleaning, laundry, bed pads and other products, according to an article in Obstetrics & Gynecology by doctors from the University of North Carolina and Duke University.

In addition to the financial costs of SUI, the condition affects quality of life because it interferes with romantic relationships, social life, work and other activities.

Conservative treatments for SUI include wearing pads, Kegel exercises, losing weight, reducing caffeine intake and avoiding strenuous activities. In severe cases, surgery may be necessary to correct incontinence. The FDA estimates 250,000 surgeries used mesh sling devices to correct SUI in 2010.

Anything that puts pressure on the pelvic floor muscles and the bladder can cause leakage, but pregnancy and childbirth are the top causes of SUI.

Giving birth can damage pelvic muscles. In addition, hormonal changes and changes to the pelvic muscles during pregnancy can affect the pelvic floor, increasing the risk of SUI.

A review published in the International Urogynecology Journal looked at data from 28 studies conducted between January 1990 and September 2012 and found that on average, about 41 percent of pregnant women experienced SUI.

In men, SUI may occur after a prostatectomy, which is a procedure to remove the prostate.

SUI and the Body

To control urination, the body uses two muscles called the sphincter and the detrusor. The sphincter is a muscle that wraps around the urethra tube, a tube that carries urine out of the body. Squeezing the sphincter stops the flow of urine. The detrusor is the bladder wall muscle. It must be relaxed for the bladder to fill with urine and contracted for it to empty.

If the pressure between these two muscles is even, a person will remain continent. When pressure on the urethra decreases but pressure on the bladder increases, a person has the urge to urinate and can do so normally. However, someone suffering from stress urinary incontinence loses control of the sphincter and is unable to control the pressures, causing leakage.

The patient is the first person to notice SUI because doctors don’t screen for it during normal checkups. When a patient complains of incontinence, a primary care doctor uses a pelvic exam or rectal exam to assess the pelvic floor.

The doctor will ask the patient to describe the episodes of leakage. The doctor may also ask the patient to keep a bladder journal. In addition, the doctor will ask about medical history and take a urine sample to test for abnormalities.

After making a diagnosis, the doctor will discuss how lifestyle factors, such as diet and exercise, can affect SUI. The doctor may refer the patient to an urologist or urogynecologist for confirmation of the type of incontinence and a detailed treatment plan.

A urinary stress test involves inserting a catheter into the bladder through the urethra to add fluid. Once the bladder is full, the patient coughs, and the doctor measures the fluid loss.

During a cystoscopy, doctors insert a small, lighted tool through the urethra into the bladder to study hard-to-view areas and to collect tissue and urine samples. This procedure is done with a numbing agent, sedative or anesthesia to avoid discomfort.

The level of treatment for stress urinary incontinence depends on the doctor, the severity of the condition and the willingness of the patient to participate in treatments. These treatments generally fall into two categories: non-invasive and surgical.

Non-Invasive Treatment

Doctors often begin treatment by suggesting the least-invasive options. Patients experiencing minimal leakage may be comfortable wearing absorbent pads and avoiding invasive procedures. They may also be willing to make some lifestyle changes to lessen symptoms of SUI.

Behavior modifications include:

• Losing weight (for patients who are obese)
• Reducing caffeine intake
• Reducing alcohol intake
• Avoiding irritating substances, such as spicy food
• Avoiding strenuous activities
• Performing Kegel exercises that strengthen the pelvic muscles

Different drug therapies can treat SUI. Collagen injections tighten the urethra, preventing urine leakage.

Medications for mild to moderate incontinence include:

• Anticholinergic drugs to control overactive bladder
• Antimuscarinic drugs to block bladder contractions
• Alpha-adrenergic agonist drugs to strengthen the sphincter
• Imipramine, a tricyclic antidepressant

Female patients also have the option of using a vaginal pessary, which is a removable silicone device inserted into the vagina to provide pelvic support. Patients must remove the device and clean it regularly. Doctors may recommend using topical estrogen in conjunction with a pessary for lubrication and to reduce irritation.

Surgical Treatment

To correct SUI, doctors can surgically insert a vaginal sling, which is a strip of material made from tissue or from man-made mesh. The sling passes under the urethra and bladder neck and is surgically anchored to surrounding tissues, raising and supporting the urethra tube. Wider slings also compress the bladder and urethra to prevent leakage.

The FDA estimates 250,000 surgeries used mesh slings to correct SUI in 2010. Most mesh sling surgeries — 70 percent to 80 percent — are successful after one year of follow up, but there are few long-term studies, according to the FDA. The agency reported similar effectiveness outcomes following surgery without mesh.

However, serious complications can occur when surgeons implant mesh slings transvaginally, or through the vagina. Thousands of women filed lawsuits against mesh sling manufacturers because of complications.

After having a vaginal sling implanted, patients may have difficulty urinating or their incontinence may return. They also face the risk of infection, internal bleeding, inflammation and pain.

In the worst-case scenario, a mesh sling can erode into nearby tissues and can perforate pelvic organs. Patients may face one or more revision surgeries to address complications, which are not always reversible.