Stress Urinary Incontinence

Contents

1. The mechanics of a leak
2. Exercises, devices and habits
3. When an operation is considered
4. What remains unsettled

Urinary incontinence is one of the conditions Candace Cooley has treated, along with menstrual disorders and menopausal symptoms, and its commonest form in women is the one researchers find hardest to bring into the open. Adonis Hijaz, a physician in Cleveland, shared a federal grant of nearly $3 million to study that silence, and told WOSU Public Media that women conceal the problem and quietly work around it. His team cites estimates that between half and seven in ten women are affected by incontinence, and describes the two main kinds: urge incontinence, a strong and frequent need to go, and stress incontinence, a small leak with a sneeze, a laugh or a run.⁴ This entry is about the second.

The mechanics of a leak

The word stress here means physical pressure, not worry. When the pelvic floor and sphincter muscles are strong they absorb the jolt of a cough, a sneeze, exercise or a laugh; when they are weak, the sudden rise in pressure pushes urine out, explains the National Institute of Diabetes and Digestive and Kidney Diseases. Most cases, it adds, come from the bladder neck dropping toward the vagina. The same booklet observes that many women leak while pregnant or after giving birth, and that female athletes of every age sometimes leak during strenuous sport.⁵

Women are more exposed than men for anatomical and life course reasons. The Office on Women’s Health notes that pregnancy, childbirth and menopause can weaken or damage the muscles that support the bladder and urethra, and that the female urethra is shorter, so any weakness is more likely to cause leakage. Extra weight, chronic constipation and pelvic surgery such as hysterectomy add strain or damage.¹ The digest of the practice bulletin published in American Family Physician puts the risk of stress incontinence 4.2 times higher in obese women than in women of normal weight, and reports that in up to 75 percent of ambulatory women with incontinence, stress leakage is the main condition.²

Figure

Incontinence in the guidance

Women living in the community affected by incontinence

Up to 70%

Ambulatory women with incontinence whose main problem is stress leakage

Up to 75%

Greater risk of stress incontinence in obese women

4.2 times

Diagnosis rests mostly on the story and a simple test. Small spurts of urine during a cough, with no urge, strongly suggest stress incontinence, while leaking that continues several seconds after the cough points toward bladder muscle overactivity instead; the cough stress test, often paired with simple filling of the bladder, may need repeating when results are borderline.² The same guidance recommends formal bladder pressure testing before surgery, except in women with an uncomplicated history, matching examination findings and no earlier incontinence surgery.² The nurses in the Cleveland study also push back on the idea that leakage is simply what happens to women after babies; chronic constipation, obesity, falling estrogen after menopause and family history can all contribute.⁴ Urgency driven leakage is treated differently and has its own entry, overactive bladder.

Exercises, devices and habits

Most treatment starts without an operation. Kegel exercises strengthen the pelvic floor and need no equipment, and the institute says fewer leaks usually follow within about six to eight weeks.⁵ In the evidence summarized by American Family Physician, pelvic floor training appears effective for stress and mixed incontinence and better than electrical stimulation or vaginal cones, and behavioral training cut leakage episodes among women with stress incontinence by 69 percent on average.² The menu the Cleveland nurses offer runs from exercise classes and physical therapy with biofeedback, which measures muscle contractions, to bladder training, lifestyle changes, medicine and surgery.⁴ Specialized coaching has its own entry, pelvic floor rehabilitation.

Figure

From the simplest step to surgery

1. 01
   ExerciseKegel exercises to strengthen the pelvic floor, often taught by a trained physical therapist.
2. 02
   HabitsLosing extra weight and choosing drinks without caffeine.
3. 03
   DeviceA pessary to lift the bladder neck, worn for exercise or all day.
4. 04
   SurgeryAn operation to support the bladder neck or urethra when other treatments fail.

A pessary, a plastic ring worn in the vagina, can lift the bladder neck and reduce stress leakage; some women wear one only for exercise and others all day.⁵ The bulletin summary is cautious, noting little objective evidence for such devices and warning that pushing a prolapsed front vaginal wall back into place can reveal leakage that the prolapse had been hiding.² That interplay is explored under pelvic organ prolapse. Losing excess weight, treating constipation and cutting back on caffeine all reduce strain on the bladder.¹

Medicines play little part. No medication has approval for treating stress leakage,⁵ and oral estrogen is not recommended for any type: smaller studies found it did not reduce leakage, and hormone therapy raised the rate of new incontinence in women who had none. For women too unwell for surgery, injections of bulking agents around the urethra may relieve symptoms for up to 12 months, though repeat injections are often needed.²

When an operation is considered

Surgery is offered when conservative treatment has not relieved symptoms enough and a woman wants further help, and it treats stress leakage only; it does nothing for urge incontinence.²⁵ Two families of operation dominate. Both raise and support the bladder neck or urethra, one with a web of stitches anchored to nearby tissue and the other with a ribbon of material beneath the urethra.⁵ Long term data show similar objective cure rates for retropubic colposuspension, known as the Burch procedure, and for slings, and both may outperform older needle suspensions, at the price of slightly more complications, longer convalescence and more trouble emptying the bladder afterward. Adding a hysterectomy does little for the Burch operation’s success and is reserved for women with a separate uterine problem.²

Over roughly a decade the midurethral sling, a narrow mesh tape set under the middle of the urethra, replaced the Burch operation as the most common procedure, according to an update in The Hospitalist. It spread quickly because it was minimally invasive and highly effective, and serious adverse events were rare.⁶ A gynecologic surgeon writing in MDedge cited a 660 woman trial in which sling surgery as the first treatment beat initial physiotherapy at one year, and noted that 49 percent of the physiotherapy group chose surgery during the study.³ The operation itself is the subject of the entry on the midurethral sling.

Figure

Sling surgery or physiotherapy first

	Initial sling surgery	Initial physiotherapy
Subjective improvement	91%	64%
Subjective cure	85%	53%
Objective cure	77%	59%

What remains unsettled

Open questions cluster around the margins. For mild stress incontinence, physiotherapy may hold its own against surgery, and the place of exercise as the routine first step has become a matter of debate as sling results improved.³ The bulletin summary found the effect of adding pelvic muscle training to other treatments unclear, and evidence on weight loss limited to dramatic loss in severely obese women.² Mesh has drawn scrutiny: some sling kits carried more mesh complications and were withdrawn, and minor changes in technique have not always meant better long term results.⁶

Newer, smaller slings add their own uncertainty. A trial of about 600 women in the New England Journal of Medicine found single incision mini slings no worse than standard midurethral slings for success at 15 months, with similar results at 36 months, but more tape or mesh exposure and more pain with intercourse, while groin or thigh pain affected about one woman in seven in both groups at three years; its background noted that standard slings were the worldwide norm only until recently.⁷ Finally, many women never ask for help at all.⁴ The right mix of exercise, devices and surgery for a particular woman is something she decides with her own clinician.