If you have stress incontinence, your bladder is not able to hold urine as securely as it should, especially when under pressure. This means that small amounts of urine are released when you sneeze, laugh, cough or undergo sudden physical exercise, such as jumping or sexual activity.
The bladder is designed to hold urine securely until you choose to visit the toilet and release it. This is achieved by a sphincter, a tight band of muscle at the base of the bladder, just at the point where it joins the urethra, the tube that carries urine out of the body. The bladder, urethra and this important sphincter muscle are supported by the muscles of the pelvic floor.
Stress incontinence can be due to problems with the sphincter, or to a weakness of the muscles and surrounding tissues. Most people experience stress incontinence occasionally, but for some people it becomes a frequent and embarrassing problem.
What causes stress incontinence?
Stress incontinence, also known as stress urinary incontinence (SUI), affects around one in five women over 40. Men can also suffer from stress incontinence but not nearly so many are troubled by it until much later in life.
Three main causes are recognised:
Weakness in the muscles of the pelvic floor. These muscles can lose tone during pregnancy, as a result of a hysterectomy or due to advancing age. Drug prescriptions, such as muscle relaxants, and the drop in oestrogen levels during menopause can also have an adverse effect on the pelvic floor, leading to stress incontinence.
Damage to the sphincter muscle itself, or to its nerve supply. Sphincter problems associated with stress incontinence can happen as a result of abdominal surgery, a pelvic fracture or a radical prostatectomy in men (performed as treatment for prostate cancer).
Overactive bladder. Muscles in the bladder wall are more ‘twitchy’ than normal, and tend to release the urine when they perceive the bladder is dangerously fully. In fact, the bladder is not full and you can train your bladder to stop recognising these signals quite so easily, so reducing stress incontinence.
Treatment at home
The first stage of treatment for stress incontinence is to remove triggers wherever possible. This includes stopping smoking, to prevent smoker’s cough putting regular stress on the bladder, and losing weight, to take the pressure off the pelvic floor muscles. Something as simple as watching what you drink and when, and making sure you don’t leave it too long before going to the toilet can all help stress incontinence.
The next step in many cases is to improve the muscle tone of the pelvic floor. Your GP, stress incontinence specialist nurse or physiotherapist will tell you how to do pelvic floor exercises effectively several times a day, to strengthen the muscles. The basic technique is to imagine you are urinating and to then contract the muscles in your pelvis that will stop the flow completely, even though the bladder is still reasonably full. Paying attention to the muscles you use should enable you to contract these muscles at will, wherever you are.
If your stress incontinence persists, several training techniques and alternatives are available:
Biofeedback: a device that signals when you are squeezing the right muscles, to help you learn the correct techniques. Once you have had biofeedback, you will be much more aware of how to do pelvic floor exercises effectively.
Vaginal cones: these small, cone-shaped weights are inserted into the vagina to help you to train your pelvic floor muscles. Just holding them in while standing up contracts the correct muscles.
Bladder training: you will be told how to train your bladder to get used to holding more urine without releasing it spontaneously. This involves ‘holding on’ for an extra minute or two, and avoiding the urge to urinate for longer and longer periods. This can work well for people whose stress incontinence is due to an overactive bladder.
Electrical muscle stimulation: this stimulates and tones the pelvic floor muscles for you if you are unable to tense and relax them yourself.
Strengthening the pelvic floor is sufficient to treat stress incontinence in around 60% of cases. If this doesn’t solve the problem then you may require drug treatment or surgery.
Currently, the National Institute of Clinical Excellence (NICE) recommends that an immediate-release formulation of the drug oxybutynin should be used as a drug treatment for women with stress incontinence, but only after pelvic floor exercises and methods of training the bladder have failed.
If this also doesn’t work, you can be prescribed other drugs such as tolterodine, solifenacin, darifenacin or trospium, or you can have an oxybutynin skin patch, which releases the drug slowly but constantly. This can produce better results in some women.
The aim of surgery for stress incontinence is to give you more control over your bladder, but it may not always offer a complete cure. The long-term effectiveness of surgery for stress incontinence depends on several factors including the original cause, your lifestyle and the type of surgery you have. Your doctor will advise on the option most suitable for you.
Surgical solutions include:
Colposuspension: this involves constructing a hammock-like structure within the abdomen to provide additional support for the urethra.
Tape insertion: this involves inserting tape to form a supportive sling for the bladder and urethra. You may have a transobturator tape or TOT procedure or a tension-free vaginal tape or TVT procedure.
Urethral bulking agents: injections of collagen are given to thicken and strengthen the walls of the urethra to help prevent urine leakage.
Artificial sphincter implant: a technique that can be offered to men to replace the natural sphincter. Some types are in development, but this is not a routine, mainstream technique for treating stress incontinence.