Stress Incontinence
Stress urinary incontinence is the involuntary leakage of urine during activities that increase intra-abdominal pressure.
Stress urinary incontinence (SUI) is one of the most common types of incontinence, particularly affecting women who have gone through childbirth or menopause, but it can also affect men (most often after prostate surgery). It can happen during activities such as coughing, sneezing, laughing, jumping, or lifting heavy objects. In stress incontinence, physical pressure (“stress”) on the bladder causes urine to leak out because the pelvic floor muscles and urethral sphincter are not able to completely resist that pressure. This is different from urge incontinence, where leakage happens with a strong urge to urinate.
Common scenarios of stress incontinence include leaking a bit of urine when you cough hard or sneeze, laugh, exercise (especially high-impact exercise like running or jumping), or lift something heavy. Some women even leak from movements like standing up from a chair or bending over, if the incontinence is more severe. The amount can range from a few drops to a small stream, depending on severity.
Why Does Stress Incontinence Happen?
The primary issue in stress incontinence is usually either:
Pelvic floor muscle weakness / urethral hypermobility: The supports for the bladder neck and urethra are weakened or stretched out, so the urethra cannot stay closed during sudden pressure increases. This is very common after vaginal childbirth, which can damage the pelvic floor and the connective tissue “hammock” that holds up the bladder and urethra. When abdominal pressure rises, instead of the urethra being compressed against a firm support, it moves downward (hypermobility) and opens, letting urine out. Risk factors for this type include childbirth, especially multiple deliveries or deliveries involving forceps or large babies, as well as aging and menopause, which lead to tissue laxity.
Intrinsic sphincter deficiency (ISD): The urethral sphincter itself is weakened and cannot generate enough closure pressure, even at rest. This can happen in older women or as a result of pelvic surgery, or in men after prostate surgery. With ISD, even minimal stress can cause leakage because the sphincter doesn’t close effectively. ISD is a more severe form, where leakage may occur even with minimal exertion or continuous dripping.
In many cases, women have a combination of these factors. After menopause, the loss of estrogen also thins the urethral lining and can reduce urethral closing pressure, contributing to SUI.
Other contributing factors:
Chronic cough or heavy lifting: These chronic stresses can gradually weaken pelvic support.
Obesity: Increases baseline pressure on the pelvic floor; studies show overweight women are more likely to have SUI, and weight loss can reduce symptoms dramatically.
Genetic connective tissue differences: Some women have naturally stretchier tissue and may develop incontinence even without pregnancies.
Prostate surgery in men: Many men experience some stress incontinence after removal of the prostate (radical prostatectomy) because one of the sphincters (at the bladder neck) is removed and the remaining sphincter may be weak.
Signs and Impact
The hallmark sign is urine leakage with physical activity or pressure and not typically associated with a sense of bladder urgency at that moment. Women with stress incontinence often say, “If I don’t brace myself and squeeze before I cough or sneeze, I leak.”
Stress incontinence can be classified by severity:
Mild: Only leaks during vigorous activity (e.g., high-impact exercise, strong sneeze).
Moderate: Leaks with daily occurrences like coughing or picking up a toddler, requiring a small pad.
Severe: Leaks with minor stresses or in large volumes, potentially necessitating full pads or diapers.
Stress incontinence does not generally cause nighttime leakage but can significantly impact confidence, physical activity, and social interactions. Many women avoid exercises they enjoy due to leakage concerns, leading to decreased fitness levels.
Prevention and Conservative Management
Preventing stress incontinence or improving it early is ideal:
Pelvic Floor Exercises: Regular Kegel exercises help maintain pelvic floor strength. Women should ideally start during pregnancy and resume postpartum once able. Even later in life, pelvic floor exercises can improve support and reduce SUI severity.
Maintain Healthy Weight: Weight loss significantly reduces SUI leakage by decreasing intra-abdominal pressure on the bladder.
Avoid Smoking and Treat Chronic Cough: Minimizing chronic strain on pelvic support can help prevent worsening symptoms.
Avoid Excessive Straining: Treat constipation and be cautious with heavy lifting.
First-Line Treatments:
Pelvic Floor Physical Therapy: A specialized therapist can ensure correct muscle contractions, address muscle imbalances, and use biofeedback to enhance results. PT can significantly improve or even cure mild to moderate SUI.
Bladder Habits: Timed voiding can help avoid overly full bladders that might be more prone to leakage.
Devices: Over-the-counter pessaries or vaginal inserts can support the urethra during activity.
Continence Pads: Using incontinence pads during exercise or outings can provide security.
Biofeedback/Electrical Stimulation: Some home devices can help train pelvic floor muscles for better control.
Medical and Surgical Treatment
If conservative measures aren’t enough, medical professionals can offer:
Continence Pessary: A fitted pessary can support the bladder neck and reduce leaks.
Urethral Bulking Injections: A bulking agent is injected into the urethra to help it stay closed. This is less invasive than surgery but typically not long-lasting.
Mid-Urethral Sling Surgery: This is the most common surgical treatment for stress incontinence. A synthetic mesh tape is placed under the mid-urethra to provide support, preventing leakage when coughing or sneezing. Success rates are high, with about 85% of women significantly improving or being cured.
Colposuspension (Burch Procedure): An older surgical method that lifts and secures the bladder neck using sutures. It has largely been replaced by slings but is still used in some cases.
Artificial Urinary Sphincter (AUS) for Men: The gold standard for men with stress incontinence after prostate surgery. It involves implanting a cuff around the urethra that the patient manually controls to open and close.
Topical Estrogen: Vaginal estrogen therapy can improve tissue health and support other treatments, particularly in postmenopausal women.
Outlook
Stress incontinence is highly treatable. Many women find that after completing childbearing, they can effectively address the issue through pelvic floor training or surgery. Early intervention, especially with pelvic floor exercises and therapy, can prevent worsening. For those who undergo surgery, success rates are high, and many wish they had sought treatment sooner.
Even after treatment, continued pelvic floor exercises help maintain strength. Those planning future pregnancies should be aware that vaginal delivery may impact previous surgical corrections. However, with exercise, physical therapy, and modern surgical options, most individuals can greatly reduce or eliminate leaks, improving confidence and quality of life.