Stress Incontinence

The ability to hold urine and control urination depends on the normal function of the lower urinary tract, the kidneys, and the nervous system. You must also have the ability to recognize and respond to the urge to urinate.

Stress incontinence is a bladder storage problem in which the strength of the muscles (urethral sphincter) that help control urination is reduced. The sphincter is not able to prevent urine flow when there is increased pressure from the abdomen.
Stress incontinence may occur as a result of weakened pelvic muscles that support the bladder and urethra or because of a malfunction of the urethral sphincter. The weakness may be caused by:

• Brain or nervous system (neurological) injury
• Injury to the urethral area
• Some medications
• Surgery of the prostate or pelvic area

Stress urinary incontinence is the most common type of urinary incontinence in women.
Stress incontinence is often seen in women who have had multiple pregnancies and vaginal childbirths, and whose bladder, urethra, or rectal wall stick out into the vagina (pelvic prolapse).

Risk factors for stress incontinence include:

• Being female
• Childbirth
• Chronic coughing (such as chronic bronchitis and asthma)
• Getting older
• Obesity
• Smoking

Symptoms

Involuntary loss of urine is the main symptom. It may occur when:

• Coughing
• Sneezing
• Standing
• Exercising
• Engaging in other physical activity

Tests and exams:

• Pelvic exam in women
• Rectal exam

In some women, a pelvic examination may reveal that the bladder or urethra is bulging into the vaginal space.

Tests may include:

• Inspection of the inside of the bladder (cystoscopy)
• Pelvic or abdominal ultrasound
• Post-void residual (PVR) to measure amount of urine left after urination
• Rarely, an electromyogram (EMG) is performed to study muscle activity in the urethra or pelvic floor
• Tests to measure pressure and urine flow (urodynamic studies)
• Urinalysis or urine culture to rule out urinary tract infection
• Urinary stress test (the patient is asked to stand with a full bladder, and then cough)

The health care provider may also measure the change in the angle of the urethra when at rest and when straining (Q-tip test). An angle change of greater than 30 degrees often means there is significant weakness of the muscles and tissues that support the bladder.

Treatment
Treatment depends on how severe the symptoms are and how much they interfere with your everyday life.
The doctor may ask that you stop smoking (if you smoke) and avoid caffeinated beverages (such as soda) and alcohol. You may be asked to keep a urinary diary, recording how many times you urinate during the day and night, and how often urinary leaking occurs.

• Inspection of the inside of the bladder (cystoscopy)
• Pelvic or abdominal ultrasound
• Post-void residual (PVR) to measure amount of urine left after urination
• Rarely, an electromyogram (EMG) is performed to study muscle activity in the urethra or pelvic floor
• Tests to measure pressure and urine flow (urodynamic studies)
• Urinalysis or urine culture to rule out urinary tract infection
• Urinary stress test (the patient is asked to stand with a full bladder, and then cough)

There are four major categories of treatment for stress incontinence:

• Behavioral changes
• Medication
• Pelvic floor muscle training
• Surgery

Behavioral changes involve decreasing how many fluids you drink, if you drink too much during the day. (You should not decrease your fluid intake if you drink normal amounts of fluids.)
Urinating more frequently may help some patients decrease the amount of urine that they leak. Constipation can make urinary incontinence worse, so dietary or medical treatments to help keep regular bowel habits are recommended.
Weight loss has been shown to help decrease symptoms in those who are overweight. Some people with severe stress incontinence may change their activity level to avoid movements such as jumping or running, which can cause greater leakage of urine.
Pelvic muscle training exercises control urine leakage. These exercises improve the strength and function of the urethral sphincter.
Biofeedback and electrical stimulation may be helpful for those who have trouble doing pelvic muscle training exercises. These two methods can help you identify the correct muscle group to work. Biofeedback is a method that helps you learn how to control certain involuntary body responses.
Electrical stimulation therapy uses low-voltage electrical current to stimulate and contract the correct group of muscles. The current is delivered using an anal or vaginal probe. The electrical stimulation therapy if offered at our clinic. Treatment sessions usually last 45 minutes and may be done every 1 - 4 days. This program is usually covered by most health insurance companies and Medicare.

Medications Used for Stress Incontinence

Alpha-Adrenergic Agonists. Alpha-adrenergic agonists, such as clonidine (Catapres), are used to strengthen the smooth muscle that opens and closes the internal sphincter. These drugs include ephedrine and pseudoephedrine, which have been common ingredients in numerous over-the-counter decongestants and appetite suppressants.

Such drugs may be helpful for select patients with mild stress incontinence not caused by nerve damage, but evidence on their benefits is weak. They also can have significant side effects, including agitation, insomnia, and anxiety. Alpha-adrenergic agonists may have adverse effects on the heart in people with existing heart problems. People with glaucoma, diabetes, hyperthyroidism, heart disease, or high blood pressure should not take these drugs.

Antidepressants

Evidence indicates that both urge and stress incontinence are affected, in part, by central nervous system processes. Investigators are particularly interested in serotonin, norepinephrine, and noradrenaline, which are chemical messengers (called neurotransmitters) that affect pathways involved with urination. (These neurotransmitters are also important for many other emotional and physical functions.) Antidepressants targeting one or both of these neurotransmitters are sometimes used for urge incontinence and may also be helpful for some people with stress incontinence.

Tricyclic Antidepressants. Tricyclic antidepressants, such as imipramine (Tofranil), may help both urge and stress incontinence. They act as anticholinergic drugs and relax the bladder. They also strengthen the internal sphincter. These drugs should be used carefully. They pose some risk for adverse effects on the heart and possibly the lungs, and they have other severe side effects in older adults. These antidepressants produce side effects similar to anticholinergic drugs, and may cause drowsiness. They may also cause overflow incontinence in some people.

Estrogen vaginal therapy (preferably with estriol vaginal crème or suppositories) can be used to improve urinary frequency, urgency, and burning in postmenopausal women. It also can improve the tone and blood supply of the urethral sphincter muscles.

Surgical treatment is only recommended after the exact cause of the urinary incontinence has been determined.