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What is stress urinary incontinence?

Stress Urinary Incontinence (SUI) is the involuntary leakage of urine during activities such as coughing, sneezing, lifting, laughing, or exercising. 

It is a common misconception that SUI is a natural part of aging. This is not true. This condition affects at least 10-20% of women, many of whom do not realize that there are simple, effective treatment options available.

SUI can negatively impact women's lives. Pressure to the bladder occurs in many different potential scenarios, thus SUI may limit women's social and personal relationships, as well as limiting physical activity.

What causes stress urinary incontinence?

There are a number of factors which can play a role in developing stress urinary incontinence. These include:

  • Pregnancy and vaginal birth
  • Obesity
  • Chronic cough
  • Constipation
  • Genetically inherited factors

How is stress urinary incontinence diagnosed?

At your appointment, Cleveland Clinic doctors will ask you questions about the activities which cause leakage and will perform a pelvic exam to determine if you have other complicating conditions such as pelvic organ prolapse. If you are experience other forms of incontinence such as urinary urge incontinence, or feces or gas incontinence, it is important that you mention them to your doctor.

What tests may be performed?

There are several potential tests that your doctor may perform in order to properly diagnose you with stress urinary incontinence or another condition that may cause urine leakage.

  • To help with diagnosis your doctor may ask you to cough while you have a comfortably full bladder,
  • You may be asked to fill in a bladder diary (otherwise known as a frequency volume chart). Recording how much you drink, as well as the number of times you pass urine and the volume passed each time. A record of the amount of leakage is also kept. Your doctor may recommend urodynamic studies. Urodynamics investigate the bladder's ability to fill and empty and the mechanism or cause of the incontinence.
  • A urine test may be performed to look for a urinary tract infection.

All these tests are designed to help plan the best treatment for each individual.

What are the symptoms of stress urinary incontinence?

Stress urinary incontinence is the leakage of urine while the bladder is under increased stress (sneezing, coughing, lifting weights, etc). Many pressure increasing activities that a woman may do happen on a daily basis, thus SUI can lead to emotional distress. However, urinary leakage doesn't necessarily have to happen every time pressure is increased on the bladder.

How is stress urinary incontinence treated?

Your physician will advise you on the best options for you, but initially you may be recommended conservative treatment to determine if simple, nonsurgical approaches can resolve the problem.

Lifestyle Changes

Modifying everyday life choices to reduce the risk of SUI requires a little planning. The first and easiest recommendation is to drink enough water to pass urine 4 to 6 times per day (for most women this is about 1.5-2 liters or half a gallon). Maintaining weight within a healthy range has been shown to reduce the severity of SUI problems; avoiding causes of constipation and cutting out smoking can also help.

Pelvic floor Exercises

Pelvic floor exercises (PFE) otherwise known as kegel exercises, can be a very effective way of improving symptoms of SUI. Up to 75% of women show an improvement in leakage after PFE training. Like all training, the benefits of pelvic floor exercises are maximized if practice is carried out regularly over a period of time. Maximum benefit usually occurs after 3 to 6 months of regular exercising. You may be referred to a therapist who specializes in teaching PFEs to supervise this. If you have a problem with urge urinary incontinence, your doctor may also advise bladder training exercise.

Continence Devices

Continence devices are available which fit in the vagina and help control leakage. These can be inserted prior to exercise or in the case of a vaginal pessary, worn continuously. Some women find inserting a large tampon prior to exercise may prevent or reduce leakage. These types of devices are most suitable for women with minor degrees of urinary incontinence or who are waiting definitive surgical treatment.

What surgical interventions are available to me?

In certain cases, lifestyle changes aren't enough to curb the problem of SUI. After following up with your doctor and determining that there hasn't been a significant change in SUI, the next step for many patients is minimally invasive surgical intervention. The aim of surgery is to correct weakness of the supports of the bladder neck. Many surgeons would want to avoid surgery until a woman's family is complete because future pregnancy may compromise the results of the initial surgery.

Midurethral Sling Procedures

Before 1993, the treatment of stress incontinence often involved major surgery with abdominal incision. The most common treatment now involves the use of a permanent sling that lies under the middle section of the urethra when you cough, sneeze, or exercise.

Following a small incision in the vaginal the sling can be put into position in a number of ways:

Retropubic slings pass under the urethra then run behind the public bone with the tape exiting out through 2 small cuts just above the pubic bone. 

Single incision sling passes under the urethra and anchored within the tissues, this type of sling has been less well studied to date. 80-90% of women undergoing retropublic or transobturator sling procedures are cured or improved of their stress incontinence symptoms following surgery. Single incision sling procedures are fairly new, and success rates are still being monitored.

This operation is not designed to cure urge incontinence/overactive bladder symptoms, although up to 50% of women notice some improvement in OAB symptoms following sling surgery. However in a small percentage of women with OAB their symptoms may be worse. Most women will have an aching discomfort in the groin for a couple of weeks. A small amount of vaginal bleeding for 7-10 days following surgery is not unusual.

Burch (Colposuspension)

For many years this was considered the main operation for the management of SUI. It is performed either through a 10-12 cm abdominal incision (open Burch) or as a laparoscopic ('key hole') approach. The surgery involves the passage of 4-6 permanent sutures that suspend the vaginal tissue underlying the bladder to the back of the pubic bone in order to support the bladder neck and urethra and restore continence. Open Burch colposuspension has a success rate similar to that of retropublic slings in long term follow up studies, and comparable results can be obtained by skilled surgeons using the laparoscopic approach.

Bulking Agents

Substances can be injected around the bladder neck and into the urethral sphincter to bulk it up and reduce the caliber of the urethra. A variety of different substances can be injected including fat and collagen. The injection can be performed in the office or outpatient surgery. An anesthetic may be required for the operation but many are performed under local anesthetic only. Some burning or stinging when urinating, after the operation, is quite common. Sometimes injections need to be repeated. Complications will vary depending on the type of bulking agent used, and you should discuss these with your doctor.

Can stress urinary incontinence be prevented?

Doing kegel exercises may help prevent symptoms. Women who are pregnant may want to do kegels during and after pregnancy to help prevent incontinence.

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