Stress Incontinence Clinic

Stress incontinence is when urine leaks because there is a sudden extra pressure within the abdomen on the bladder. This pressure (or stress) is caused by things like coughing, laughing, sneezing or exercising (such as running or jumping). Weakened pelvic floor muscles cannot support the bladder and urethra so well. The pressure is too much for the bladder outlet to withstand and so urine leaks out. Small amounts of urine may leak, but sometimes it can be quite a lot and can cause embarrassment.

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. Older women, more often than younger women experience incontinence. But incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages.

Stress incontinence may occur from weakened pelvic muscles that support the bladder and urethra or because the urethral sphincter is not working correctly. Weakness may be caused by:

• Childbirth
• Injury to the urethra area
• Some medications
• Surgery in the prostate or pelvic area

Risk factors for stress incontinence include:

• Female gender
• Childbirth
• Coughing over a long period of time (such as chronic bronchitis and asthma)
• Getting older
• Obesity
• Smoking

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.

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

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 the bladder as it fills and empties. Warm water mixed with a dye that shows up on X-rays is gradually instilled in the 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.

Treatment depends on how severe your symptoms are and how much they affect your everyday life. Treatment for stress incontinence include:

• Behaviour changes
• Medication
• Pelvic floor muscle training
• Surgery

Behaviour changes

• Drinking less fluid (if you drink more than normal amounts of fluid)
• Urinating more often to reduce the amount of urine that leaks
• Avoiding jumping or running, which can cause more urine to leak
• Making your bowel movements more regular by taking dietary fibre or laxatives to avoid constipation (which can make incontinence worse)
• Quitting smoking to reduce coughing and bladder irritation (and your risk of bladder cancer)
• Avoiding alcohol and caffeine, which can stimulate the bladder
• Losing weight if you are overweight
• Avoiding food and drinks that irritate the bladder, such as spicy foods, carbonated drinks and citrus fruits
• 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 keep the urethral sphincter strong and working properly.
• Some women may use a device called a vaginal cone with pelvic exercises. You place the cone into the vagina. Then you try to squeeze the pelvic floor muscles to hold the cone in place. You can wear the cone for up to 15 minutes at a time, twice a day. Within 4 to 6 weeks, most women have some improvement in their symptoms.
• Biofeedback and electrical stimulation may be helpful for people who have trouble doing pelvic muscle training exercises. These two methods can help you find the correct muscle group to work. Biofeedback can also help you learn how to control certain body responses.
• Electrical stimulation therapy uses a 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 healthcare provider’s office or at home.
• Treatment sessions usually last 20 minutes and may be done every 1 to 4 days. Newer techniques are being studied. One new technique uses an electromagnetic chair to make the pelvic floor muscles contract when the person is sitting.

Medications

• Anticholinergic drugs control overactive bladder (oxybutynin, tolterodine, Enablex, Sanctura, Vesicare, Oxytrol)
• Antimuscarinic drugs block bladder contractions (many healthcare providers 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. However, these drugs are rarely prescribed because of possible side effects on the heart
• Imipramine, a tricyclic antidepressant, works much like the alpha-adrenergic and anticholinergic drugs

Surgeries

Surgery is only recommended after the exact cause of urinary incontinence has been found. Most of the time, your healthcare provider will try bladder retraining or Kegel exercises before considering surgery.

• Anterior vaginal repair or paravaginal repair procedures are often done in women when the bladder is bulging into the vagina (called a cystocele). Anterior repair is done through a surgical cut in the vagina. 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).
• Male sling is a newer procedure that can be done in certain men. It is easier to do than placing an artificial urinary sphincter.
• Retropubic suspensions are a group of surgical procedures done to lift the bladder and urethra. They are done through a surgical cut in the abdomen.
• Tension-free vaginal tape
• Vaginal sling procedures are often the first choice for treating stress incontinence in women (they are rarely done in men). A sling is placed that supports the urethra.

Behaviour changes, pelvic floor exercise therapy, and medication usually improve symptoms. However, they will not cure stress incontinence. Surgery can cure patients, if they are good candidates.
Treatment does not work as well in people with:

• Conditions that prevent healing or make surgery more difficult
• Other genital or urinary problems
• Past surgery that did not work

Availability of Urodynamics and Videourodynamics is required to quantify the pathology. The Incontinence Team with vast experience of open and minimally invasive surgeries for the above problem available.