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Stress incontinence is losing urine without meaning to during physical activity, such as coughing, sneezing, laughing, or exercise.

Causes

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

Symptoms

The main symptom of stress incontinence is losing urine without your control. It may occur when you:

• Cough
• Exercise
• Have sexual intercourse
• Sneeze
• Stand
• Take part in physical activity

Exams and Tests

The health care provider will perform a physical exam, including a:

• Genital exam in men
• Pelvic exam in women
• Rectal exam

In some women, a pelvic examination may show that the bladder or urethra is bulging into the vagina. Tests may include:

• Electromyogram (EMG) is (rarely) done to study muscle activity in the urethra or pelvic floor
• Pad test (you are asked to exercise while wearing a sanitary pad– after you exercise, the pad is weighed to find out how much urine you have lost)
• Pelvic or abdominal ultrasound
• Post-void residual (PVR) to measure the amount of urine left after urination
• Tests to measure pressure and urine flow (urodynamic studies)
• Test to view the inside of the bladder (cystoscopy)
• Urinalysis or urine culture to rule out urinary tract infection
• Urinary stress test (you are asked to stand with a full bladder, and then cough)
• X-rays with contrast dye of the kidneys and bladder

Treatment

Treatment depends on how severe your symptoms are and how much they affect your everyday life. There are different types of treatment for stress incontinence:

BEHAVIOR CHANGES:

Examples of behavior changes include:

• 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 fiber 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.

• 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 health care provider’s office or at home.

MEDICATIONS:

Medicines tend to work better in patients with mild to moderate stress incontinence. There are several types of medications that may be used alone or in combination. They include:

• Anticholinergic drugs control overactive bladder (oxybutynin, tolterodine, Enablex, Sanctura, Vesicare, Oxytrol)
• Antimuscarinic drugs block bladder contractions (many health care 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.
• Imipramine, a tricyclic antidepressant, works much like the alpha-adrenergic and anticholinergic drugs
• Estrogen therapy can be used to improve urinary frequency, urgency, and burning in women who have gone through menopause. It also can improve the tone and blood supply of the urethral sphincter muscles.

However, it is not clear whether estrogen treatment improves stress incontinence. Some hormone treatments given after menopause have been shown more harmful than helpful to women’s health. Women who have a history of breast or uterine cancer usually should NOT use estrogen therapy to treat stress urinary incontinence.

Absorbent pads and Urinary catheters:

Incontinence products such as absorbent pads can be enormously helpful. They can prevent leaking onto your clothes, control odor, and prevent skin irritation. The best choice depends on your symptoms. If you’re just having occasional leaking or dribble, a drip collector, an absorbent padded sheath that goes around the penis — might do the trick. For mild cases, an incontinence pad inserted into the underwear and held in place with an adhesive strip might work. If you’re having more severe incontinence, a larger guard or pair of absorbent underwear may be what you need. External catheters – Unlike the catheters used at the hospital, external catheters for male incontinence are silicone or latex devices that go over the penis instead of into the urethra. They’re usually rolled on like condoms. The urine is sent through a tube into a drainage bag. Some men only use these devices at night. To prevent leaks, it’s very important to get the right fit and to follow the instructions from the manufacturer.

TOT (Trans obturator tape insertion):

There is a new type of surgical treatment called transobturator tape for stress incontincne, which is used to create a hammock in the same way as an older treatment called tension free trans vaginal tape (TVT). The new procedure is known medically as TVT-O. Both treatments support the urethra and help it to close more tightly when the abdominal pressure is raised during coughing or exercising. The tape stays in place permanently. The procedure takes place under a general or spinal anaesthetic. A small incision (about 2 cm) is made in the vagina just below the opening of the urethra. A polypropylene tape (similar to the material used for surgical sutures) is passed outwards through small (0.5 cm) incisions made in the inner thigh. The tape is positioned without tension under the urethra and acts as a ‘backboard’ to support the urethral continence mechanism (sphincter) when coughing. The incisions are the closed with dissolvable stitches which disappear within 2-3 weeks of surgery. The TVT-O procedure takes about 30 minutes.

TVT (Trans vaginal tape insertion):

Traditional Tension Free Vaginal Tape (TVT) is designed for the same purpose as Transobturator tape, but is fitted in a different way. During both operations the surgeon places the tape under the middle part of your urethra. If the surgeon uses the traditional TVT method, the tape ends are passed behind your pubic bone and out through 0.5cm cuts in your abdomen, just above your pubic area. In the TVT-O the tape ends are passed sideways through a natural space in your pelvic bone through small incisions in your inner thigh. This means the surgeon does not go near to the bladder, reducing the risk of damage to the bladder, bowel or blood vessels. There is no need to cut your abdomen. The traditional TVT tape is passed around the urethra and can cause urethral compression, resulting in voiding difficulty or retention of urine. Since the TVT-O tape is passed laterally below the urethra, the tape is less compressive and the rate of voiding difficulty is significantly lower. The TVT-O tape is placed away from the bladder and causes less bladder irritation and secondary urge (overactive) symptoms, which occur in 10–15% of women after TVT tape placement.

SURGERIES:

Surgery is only recommended after the exact cause of urinary incontinence has been found. Most of the time, your health care 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.

Most health care providers recommend that their patients try other treatments before having surgery. Depending on the success of treatment and other medical problems you have, you may need a urinary catheter to drain urine from the bladder.

Authored By : Dr. Mahendra Jain