You must have a normal function of the lower urinary tract, the kidneys, and the nervous system to be able to hold urine and control urination.You must also have the ability to recognize and respond to the urge to urinate.
The average adult bladder can hold over 2 cups (350ml – 550 ml) of urine. Two muscles are involved in the control of urine flow:
- The sphincter, which is a circular muscle surrounding the urethra. You must be able to squeeze this muscle to prevent urine from leaking out.
- The detrusor, which is the muscle of the bladder wall. This must stay relaxed so that the bladder can expand.
In stress incontinence, the sphincter muscle and the pelvic muscles, which support the bladder and urethra, are weakened. The sphincter is not able to prevent urine flow when there is increased pressure from the abdomen (such as when you cough, laugh, or lift something heavy).There also could be malfunction of the urethral sphincter.
Stress urinary incontinence (SUI) is the most common type of urinary incontinence in women.
SUI 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).
Also,chronic coughing (such as chronic bronchitis and asthma),getting older,being obese and smoking put you at risk.
At times it might be due to the fact that you have a urinary tract infection.
Leakage can occur when coughing,sneezing,standing,exercising,during sexual intercourse
You will need treatment if this really affects your daily living. Stop smoking (if you smoke) and avoid caffeinated beverages (such as soda) and alcohol. Keep a urinary diary, recording how many times you urinate during the day and night, and how often urinary leaking occurs.
There are four major categories of treatment for stress incontinence:
- Behavioral changes
- Pelvic floor muscle training
Examples of behavior changes include:
- Decreasing any excessive fluid intake (you should not decrease your fluid intake if you drink normal amounts of fluid)
- Urinating more frequently to decrease the amount of urine that leaks
- Changing physical activities to avoid jumping or running movements, which can cause more urine leakage
- Regulating bowel movements with dietary fiber or laxatives to avoid constipation (which can worsen incontinence)
- Quitting smoking to reduce coughing and bladder irritation (and your risk of bladder cancer)
- Avoiding alcohol and caffeine, which can overstimulate the bladder
- Losing weight if you are overweight
- Avoiding food and drinks that irritate the bladder, such as spicy foods, carbonated beverages, and citrus
- Keeping blood sugar under control if you have diabetes
PELVIC FLOOR MUSCLE TRAINING
Pelvic muscle training exercises (called Kegel exercises) may help control urine leakage. These exercises improve the strength and function of the urethral sphincter.
Some women may use a device called a vaginal cone along with pelvic exercises. The cone is placed into the vagina, and the woman tries to contract the pelvic floor muscles in an effort to hold it in place. The device may be worn for up to 15 minutes. This procedure should be done two times a day. Within 4 – 6 weeks, most women have some improvement in their symptoms.
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 may be done at the doctor’s office or at home.
Treatment sessions usually last 20 minutes and may be done every 1 – 4 days. Newer techniques are being investigated, including one that uses a specially designed electromagnetic chair that causes the pelvic floor muscles to contract when the patient is seated.
Medicines tend to work better in patients with mild to moderate stress incontinence. There are several types of medications that may be used alone or in combination. They include:
- Anticholinergic agents (oxybutynin, tolterodine, enablex, sanctura, vesicare, oxytrol)
- Antimuscarinic drugs block bladder contractions (many doctors prescribe these types of drugs first)
- Alpha-adrenergic agonist drugs, such as phenylpropanolamine and pseudoephedrine (common ingredients in over-the-counter cold medications), help increase sphincter strength and improve symptoms in many patients
- Imipramine, a tricyclic antidepressant, works in a similar way to alpha-adrenergic drugs
Estrogen therapy 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.
However, whether estrogen treatment improves stress incontinence is controversial. Women with a history of breast or uterine cancer usually should NOT use estrogen therapy,at least at this time of the understanding of the science, for the treatment of stress urinary incontinence.
Surgical treatment is only recommended after the exact cause of the urinary incontinence has been determined. Most of the time, your doctor will try bladder retraining or Kegel exercises before considering surgery.
- Anterior vaginal repairor paravaginal repair procedures are often done in women when the bladder is bulging into the vagina (a condition is called a cystocele). Anterior repair is done through a surgical cut in the vagina, and a paravaginal repair is done through a surgical cut in the vagina or abdomen
- Artificial urinary sphincter is a surgical device used to treat stress incontinence mainly in men (rarely in women)
- Collagen injections make the area around the urethra thicker, which helps control urine leakage (the procedure may need to be repeated after a few months to achieve bladder control)
- Retropubic suspension are a group of surgical procedures done to lift the bladder and urethra. They are done through a surgical cut in the abdomen. The Burch colposuspension and Marshall-Marchetti-Krantz (MMK) procedures differ based on the structures that are used to anchor and support the bladder
- Tension-free vaginal tape
- Vaginal sling procedures are often the first choice for the treatment of uncomplicated stress incontinence in women (it is rarely done in men). A sling made of synthetic material is placed so that it supports the urethra
Most health care providers advise their patients to try other treatments before having surgery.
Depending on the success of treatment and other medical problems the person may have, some people may require a urinary catheter to drain urine from the bladder.
What is the outlook of ths condition:Behavioral changes, pelvic floor exercise therapy, and medication usually improve symptoms rather than cure stress incontinence. Surgery can cure most carefully selected patients.
Treatment does not work as well in people with:
- Conditions that may prevent healing or make surgery more difficult
- Other genital or urinary problems
- Previous surgical failures
What are the possible complications:Complications are rare and usually mild. They can include:
- Erosion of surgically placed materials such as a sling or artificial sphincter
- Fistulas or abscesses
- Irritation of the vulva (vaginal lips)
- Pain during intercourse
- Skin breakdown and pressure ulcers in bed- or chair-bound patients
- Unpleasant odors
- Urinary tract infections
- Vaginal discharge
The condition may affect or disrupt social activities, careers, and relationships.
When to Contact a Medical Professional
Call for an appointment with your health care provider if you have symptoms of stress incontinence and they are bothersome.
Performing Kegel exercises (tightening the muscles of the pelvic floor as if trying to stop the urine stream) may help prevent symptoms. Doing Kegel exercises during and after pregnancy can decrease the risk of developing stress urinary incontinence after childbirth.
A recent report from Washington showed that trials of vaginal and urinary inserts are worthwhile for managing stress urinary incontinence (SUI) in women who are young, women with episodic leakage related to certain activities, or in women who – for various reasons – are not yet ready for a surgical repair or are at high risk from any invasive procedure, Dr. Deborah J. Lightner said.
“It’s unfortunate, but many women currently manage their incontinence with pads,” said Dr. Lightner during a discussion of office-based management of stress urinary incontinence (SUI) at the meeting.
The mainstay of SUI management is still active pelvic floor muscle training that’s taught and done correctly. But when this is unsuccessful, and when no neurologic abnormalities are detected, pessaries and other inserts – in some cases, a simple tampon – deserve consideration, she said.
Research has shown that many women buy pads and tampons for the purposes of helping with urinary leakage and that three-quarters of women who use a tampon or other vaginal insert for mild SUI will be dry with that insert. “Many women know about tampons [for this purpose], but if not, you can offer them a very simple management strategy,” she said.
A tampon may be the best option, for instance, for a 24-year-old woman who leaks when playing soccer and only rarely at other times, especially if pelvic floor management training has provided no relief and if she is planning to have children. “This is an incredibly common scenario. [Urinary leakage] is a real barrier to women’s participation in high-impact activities and sports,” said Dr. Lightner, a professor of urology at the Mayo Clinic in Rochester, Minn.
Pessaries are widely available and mainly used for prolapse, but there are a variety of “highly effective” incontinence rings and dishes that provide external compression of the bladder neck, Dr. Lightner said.
Early discontinuation of pessaries and other inserts “can be expected in about one-third of patients [who try them], but when [the inserts] are well tolerated, there’s very high long-term success,” she said.
Among women who were randomized to use an intravaginal pessary in the Ambulatory Treatments for Leakage Associated With Stress Incontinence (ATLAS) trial, 63% were satisfied at 3 months, 33% had no bothersome SUI, and more than 50% had a greater than 75% reduction in their urinary leakage, she said. Results of the ATLAS trial were reported last year.
Refitting of pessaries is not uncommon, she noted,until an ultimate proper fit is achieved.
Minor complications can commonly also occur. These could be vaginal bleeding, extrusion, severe vaginal discharge, pain, and constipation, in decreasing order.Urinary tract infections can occur with frequent or long-term use;so also calcification and erosion also can occur, but “mainly with indwelling inserts, and not with episodic use.”
“Women will decide early on if this is the right option for them,” Dr. Lightner said. “And if it’s not, they can move on to other therapies.”Clinical experience over the past 2 decades with urethral inserts has been “somewhat challenging,” she said.
Thre is an insert that can be placed inside the urethra (the opening of your bladder) called FemSoft urethral insert.It is the only one currently available in the United States and it will control continence in about 90 of 100 women in 2 years of use.However early discontinuation occurs in up to 40% of users.
The urethral insert may have a role for women who wish to postpone or avoid surgery, she said.
Pelvic floor muscle training – the first-line management option for SUI – is often inadequately taught to women, she emphasized.
“It can’t be effective it’s not done correctly, so I’d have that as part of my physical exam … find out, what can she do with her pelvic floor?”
Expert Analysis from the Annual Meeting of the American Urological Association