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updated October 16, 2010

Stress incontinence

Filed under: Boomer's Health
Urinary incontinence is the unintentional loss of urine. Stress incontinence is prompted by a physical movement or activity — such as coughing, sneezing or heavy lifting — that puts pressure (stress) on your bladder. Stress incontinence is not related to psychological stress.

Stress incontinence is much more common in women.

If you have stress incontinence, you may feel embarrassed, isolate yourself, or limit your work and social life, especially exercise and leisure activities. With treatment, you'll likely be able to manage stress incontinence and improve your overall well-being.

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If you have stress incontinence, you may experience urine leakage when you:

  • Cough
  • Sneeze
  • Laugh
  • Stand up
  • Lift something heavy
  • Exercise

You may not experience incontinence every time you do one of these things, but any pressure-increasing activity can make you more vulnerable to unintentional urine loss, particularly when your bladder is full.

When to see a doctor
Talk to your doctor if the signs and symptoms of stress incontinence interfere with your activities of daily living, such as your work, hobbies and social life.

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Stress incontinence occurs because of poor function in the muscles that support the bladder or control the release of urine. Sometimes both muscle groups are involved. The bladder expands as it fills with urine, but valve-like muscles at each end of the urethra — the short tube through which urine flows to exit your body — normally stay closed, or contracted, preventing urine release until you reach a bathroom. When the muscles supporting the bladder are weak, however, pressure can trigger urine release before you're ready. Problems with the valves themselves (the urinary sphincters) may have the same effect.

Your bladder may not even feel unusually full when you have urine leakage due to stress incontinence. Anything that exerts force on the abdominal muscles — sneezing, bending over, lifting, laughing hard — also puts pressure on your bladder.

Your urinary sphincter and pelvic floor muscles may lose tone because of:

  • Childbirth. In women, poor function of pelvic floor muscles or the sphincter may occur because of tissue or nerve damage incurred during delivery of a child. Stress incontinence from this damage may begin soon after delivery or occur years later.
  • Prostate surgery. In men, the most common factor leading to stress incontinence is the surgical removal of the prostate gland (prostatectomy) to treat prostate cancer. Because the prostate gland encircles the urethra, a prostatectomy results in less urethral support.

Contributing factors
Other factors that may worsen stress incontinence include:

  • Urinary tract infection
  • Illnesses that cause chronic coughing or sneezing
  • Obesity
  • Smoking, which can cause frequent coughing
  • Diabetes, which can cause excess urine production and nerve damage
  • Excess consumption of caffeine or alcohol
  • Medications that cause a rapid increase in urine production
  • Sports, such as tennis or running

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Factors that increase the risk of developing stress incontinence include the following:

  • Age. Although stress incontinence isn't a normal part of aging, physical changes associated with aging, such as the weakening of muscles, may make you more susceptible to stress incontinence. Also, women in menopause lose the beneficial effects of estrogen — that is, strengthening and protecting the tissues of the vagina and urethra — making the development of stress incontinence more likely.
  • Type of childbirth delivery. Forceps delivery of a baby may be associated with a greater risk of stress incontinence than is normal vaginal delivery. Multiple vaginal deliveries also may be associated with a higher risk.
  • Body weight. People who are overweight or obese have a much higher risk of stress incontinence. Excess weight increases pressure on the abdominal organs. Subsequently, the "resting" pressure on the bladder may be increased even without the additional pressure from a cough or other force.
  • Previous pelvic surgery. Hysterectomy in women and particularly prostate surgery in men can alter the function and support of the bladder and urethra, making it much more likely for a person to develop stress incontinence. This effect can be either immediate or delayed.

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Complications of stress incontinence may include:

  • Personal distress. If you experience stress incontinence, you may feel embarrassed and distressed by the condition. It often disrupts work, social activities, interpersonal relationships and sexual relations.
  • Mixed urinary incontinence. Mixed incontinence usually involves both stress incontinence and urge incontinence — the loss of urine resulting from an involuntary contraction of bladder muscles (overactive bladder).
  • Skin rash or irritation. Skin that is constantly in contact with urine is likely to be irritated, sore and can break down. This can happen with severe incontinence if you don't take precautions, such as using moisture barriers or incontinence pads. However, use of incontinence products can cause further embarrassment and personal distress.

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Your doctor may use a questionnaire to make a preliminary assessment of your stress incontinence symptoms. You may also be asked to keep a voiding diary for a few days. You'll record when, how much and what kind of fluids you consume, as well as when you urinate and when you experience incontinence. Your diary may reveal patterns that help your doctor understand symptoms and identify contributing factors.

Specialized testing may require referral to a specialist in urinary disorders (urologist) or urinary disorders in women (urologist or urogynecologist).

What you can do
To get the most from your visit to the doctor, prepare in advance:

  • Write down any symptoms you're experiencing. Include all of your symptoms, even if you don't think they're related.
  • Make a list of any medications or vitamin supplements you take, regardless of how common you think they are. Many over-the-counter supplements can irritate the urinary tract. Also write down doses and how often you take the medication.
  • Have a family member or close friend accompany you. You may be given a lot of information at your visit, and it can be difficult to remember everything.
  • Take a notebook or notepad with you. Use it to write down important information during your visit.
  • Prepare a list of questions to ask your doctor. List your most important questions first, in case time runs out.

For urinary incontinence, some basic questions to ask your doctor include:

  • Will my urinary incontinence go away eventually?
  • What tests might I need to determine the cause of my incontinence?
  • Will changing my diet help with my incontinence?
  • How does my weight affect my condition?
  • Could pelvic floor exercises help me? How do I do them?
  • Could the medicines I take be aggravating my condition?
  • Are there any medications that would help with my bladder control?
  • What additional testing will I need to undergo?
  • Will I need surgery?

Make sure that you understand everything your doctor tells you. Don't hesitate to ask your doctor to repeat information or to ask follow-up questions for clarification.

What to expect from your doctor
Be prepared to answer questions from your doctor. Potential questions your doctor might ask include:

  • How often do you leak urine?
  • When you leak urine, is it a few drops or are your clothes soaked?
  • Do you leak urine when you laugh, cough, sneeze or lift heavy objects?
  • Do you leak urine when you exercise?
  • How often do you urinate in the toilet during the day?
  • Do you wake up at least twice during the night to urinate?
  • What's your typical daily fluid intake?
  • Do you drink beverages with caffeine or alcohol? How many each day?
  • Does anything seem to make your incontinence better? How about worse?
  • What's the most bothersome aspect of your problem with urinary incontinence?

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During a basic diagnostic work-up, your doctor looks for clues that may also indicate contributing factors. The exam will likely include:

  • A medical history
  • A complete physical examination with particular focus on your abdomen and genitals
  • A urine sample to test for infection, traces of blood or other abnormalities
  • A neurological exam to identify sensory problems
  • A urinary stress test, in which the doctor observes urine loss when you cough or bear down

Specialized tests
Your doctor may order urodynamic tests, which are used to assess the function of your bladder. Common tests include:

  • Measurements of postvoid residual urine. When you urinate or experience urinary incontinence, your bladder may not empty completely. To measure residual urine after you have voided, a thin tube (catheter) is passed through the urethra and into your bladder. The catheter drains the remaining urine, which can then be measured. Alternatively, a specialist may use an ultrasound scan, which translates sound waves into an image of your bladder and its contents.
  • Measuring bladder pressure. Cystometry measures pressure in your bladder and in the surrounding region during bladder filling. A catheter is used to fill your bladder slowly with warm water. This procedure, when combined with a voiding study, tells whether the muscle that connects the urethra to the bladder (urinary sphincter) exerts enough pressure to keep the urethra closed as bladder pressure rises.
  • Creating images of the bladder as it functions. Video urodynamics use either X-ray or ultrasound waves to create pictures of your bladder as it's filling and emptying. Warm water mixed with a dye that shows up on X-rays is gradually instilled in your bladder via a catheter while the images are recorded. When your bladder is full, the imaging continues as you urinate to empty your bladder. This test is often combined with cystometry.

You and your doctor can review the results of these tests and decide on a treatment strategy.

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Your doctor is likely to recommend a combination of treatment strategies to end or lessen the number of incontinence episodes. If an underlying cause or contributing factor, such as a urinary tract infection, is identified, you'll also receive treatments to address those conditions.

Behavioral therapies
Behavioral therapies may help you eliminate or lessen episodes of stress incontinence. The stress incontinence treatments your doctor will recommend may cover the following areas:

  • Fluid consumption. Your doctor may recommend the amount and timing of fluid consumption during the day. You should also avoid caffeinated and alcoholic beverages.
  • Healthy lifestyle changes. Quitting smoking or losing weight may lessen your vulnerability to stress incontinence and improve symptoms if you do have stress incontinence.
  • Scheduled toilet trips. Your doctor may recommend a schedule for toileting. More frequent voiding of the bladder may reduce the number or severity of stress incontinence episodes.
  • Pelvic floor muscle exercises. Exercises called Kegels strengthen your pelvic floor muscles and urinary sphincter. Your doctor or a physical therapist can help you learn how to do these exercises correctly. How well Kegels work for you will depend on your willingness to perform the exercises regularly, just like any other exercise routine.

Certain devices designed for women may help control stress incontinence, including:

  • Vaginal pessary. This ring-shaped device, fitted and put into place by your doctor or nurse practitioner, helps support your bladder to prevent urine leakage. A vaginal pessary may be a good choice if you wish to avoid surgery.
  • Urethral inserts. This small tampon-like disposable device inserted into the urethra acts as a plug to prevent leakage. It's usually used to prevent incontinence during a specific activity, but it may be worn throughout the day. Urethral inserts aren't meant to be worn 24 hours a day.

Surgical interventions to treat stress incontinence are generally designed to improve closure of the sphincter or support the bladder neck. Surgical interventions include:

  • Injectable bulking agents. Collagen, synthetic sugars or gels may be injected into tissues around the upper portion of the urethra. These materials increase pressure on the urethra, improving the closing ability of the sphincter. Because this intervention is relatively noninvasive and inexpensive, it may be an appropriate treatment alternative to try before other surgical options.
  • Open retropubic colposuspension. This procedure is often used to treat women with stress incontinence. Sutures attached either to ligaments or to bone lift and support tissues near the bladder neck and upper portion of the urethra.
  • Sling procedure. In this procedure most often performed in women, the surgeon uses the person's own tissue or a synthetic material to create a "sling" that supports the urethra. Slings for men are used less frequently, but this surgical approach is under investigation. A recently developed technique using a mesh sling has proved effective in easing symptoms of stress incontinence in men.
  • Inflatable artificial sphincter. This surgically implanted device is more often used to treat men. A cuff, which fits around the upper portion of the urethra, replaces the function of the sphincter. Tubes connect the cuff to a pressure-regulating balloon in the pelvic region and a manually operated pump in the scrotum. If the device is implanted in a woman, the pump is in the labia.

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Healthy lifestyle practices can go a long way toward easing symptoms of stress incontinence.

  • Shed extra weight. If you're overweight — your body mass index (BMI) is 25 or higher — losing excess pounds can help reduce the overall pressure on your bladder and pelvic floor muscles. Losing 5 to 10 percent of your body weight may help improve your stress incontinence.
  • Add fiber to your diet. Constipation contributes to incontinence, especially if you often strain during bowel movements. Keeping your bowel movements soft and regular allows urine to flow freely and reduces the strain that's placed on your pelvic floor muscles. Eat high-fiber foods — whole grains, legumes, fruits and vegetables — to relieve and prevent constipation.
  • Avoid eating or drinking substances that can irritate your bladder. For instance, if you know that drinking coffee throughout the day tends to make you go to the bathroom more frequently, try reducing the amount you drink.
  • Maintain proper fluid intake. Drinking too much fluid can make you urinate more frequently. But not drinking enough can lead to a concentration of waste in your urine, which can irritate your bladder, too.
  • Don't smoke. Smoking can lead to a severe chronic cough, which can aggravate the symptoms of stress incontinence.

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Treatments today for stress incontinence can usually substantially reduce, if not eliminate, urinary leakage and help you regain control of your bladder. Still, you may need to cope with the effects of incontinence while waiting for surgery or for medication or behavior therapies to gain effectiveness.

Going out and about
Maintaining your connection with family, friends and colleagues can prevent feelings of isolation and depression that can accompany incontinence. Being prepared may help you feel more comfortable when you're out and about:

  • Stock up on supplies. Take along sufficient incontinence pads or protective undergarments and possibly a change of clothes. Incontinence products are discreet and often can be stowed in a roomy purse or a small backpack.
  • Scout out your destination. Familiarize yourself with the restrooms available at your destination. Choose seating that allows easy access to restrooms.
  • Take good care of yourself. Prolonged contact with wet clothing can cause skin irritation or sores. Keep your skin as dry as possible to prevent this.

Sexuality and incontinence
Leaking urine during sexual intercourse can be upsetting, but it doesn't necessarily have to get in the way of intimacy:

  • Talk with your partner. As difficult as this may be initially, be upfront with your partner about your condition. You may be surprised at how understanding and willing to accommodate your needs your partner can be.
  • Empty your bladder beforehand. To reduce your chances of leakage, avoid drinking fluids for an hour or so before sex and empty your bladder immediately before starting.
  • Try a different position. Altering positions may make intercourse easier for you. For women, being on top generally gives better control of the pelvic muscles.
  • Do your Kegels. Pelvic floor muscle exercises (Kegel exercises) can help strengthen your pelvic floor muscles and reduce urine leakage.
  • Be prepared. Having towels handy or using disposable pads on your bed may help ease some of your anxiety if you're worried about leakage.

Seeking help
Being incontinent is not a normal part of aging and not something that you have to learn to live with. Treatments are usually available to cure incontinence or significantly reduce its effects on your life. The first step is finding a doctor who's interested in your condition and willing to work with you to find the best way to treat your incontinence.

You might also consider joining a support group. Organizations such as the National Association for Continence (NAFC) can provide you with resources and information about people who experience stress incontinence. Support groups offer a venue for voicing concerns and often provide motivation to maintain self-care strategies.

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