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Stress incontinence

Urinary incontinence is unintentionally leaking urine. Stress incontinence is when you suddenly leak urine because of increased pressure on your bladder. For example, this might be when you sneeze, cough or lift something heavy.

Stress incontinence is a common type of incontinence. It affects more women than men but can develop in anyone at any age.

Other types of urinary incontinence include:

  • urge incontinence – when you have a sudden and intense urge to pass urine that is usually followed by unintentionally leaking urine
  • mixed urinary incontinence – when you unintentionally pass urine because of both stress and urge incontinence
  • overflow incontinence (chronic urinary retention) – when your bladder doesn't empty properly, which causes urine to ‘spill’ out
  • overactive bladder syndrome – when you have a sudden and intense urge to pass urine and need to do so often, particularly at night

If you have severe stress incontinence, you might constantly leak urine. This can happen if your urethral sphincter doesn’t close properly. This is a group of muscles that surrounds your urethra and keeps urine in your bladder. Your urethra is the tube that carries urine from your bladder out through your penis or vulva. Your urethral sphincter usually closes automatically when there is pressure on your bladder.

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Image showing the organs of the female pelvis

Details

  • Symptoms Symptoms of stress incontinence

    If you have stress incontinence, small amounts of urine leak from your bladder when it’s under sudden pressure. This can be when you laugh, cough, sneeze, walk, exercise or lift a heavy object. It can also happen if you change position, for example, go from sitting to standing. If you carry out any movement that suddenly increases the pressure on your bladder, it can cause the uncontrollable loss of small amounts of urine.

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  • Diagnosis Diagnosis of stress incontinence

    Your GP will ask about your symptoms and examine you. They may also ask you about your medical history.

    Your GP may ask you to keep a ‘bladder diary’, probably for at least three days. This will involve recording how much you drink, when you pass urine and the amount of urine you produce. Your GP will also ask you to make a note if you had an urge to go to the toilet and the number of times you unintentionally leak.

    Your may be asked to do a pad test. This involves wearing an incontinence pad and weighing it before and after doing a series of exercises that tend to cause stress incontinence. The increased weight of the pad will show how much urine you lose.

    You will probably be asked to provide a urine sample. This can be tested to see if you have an infection in your urinary tract that could be causing incontinence. Your urinary tract consists of your kidneys, two ureters (the tubes that connect each kidney to your bladder), your bladder and urethra. Your GP may also do a blood test to check that your kidneys are working properly.

    Your GP may check to see if you leak urine when you cough or strain.

    You may be referred to a urologist (a doctor who specialises in identifying and treating conditions that affect the urinary system). Women may be referred to a gynaecologist (a doctor who specialises in women’s reproductive health). Alternatively, your GP may recommend you see a urogynaecologist (a doctor who specialises in urinary and associated pelvic problems in women).

    Other tests for stress incontinence include the following.

    • Ultrasound. This uses sound waves to produce an image of your kidneys, bladder and urethra and will check that your bladder is emptying properly.
    • Cystoscopy. This is a procedure used to look inside your bladder and urinary system.
    • Urodynamic testing. This will measure the pressure in your bladder and the flow of urine.
  • Treatment Treatment of stress incontinence

    Self-help

    There are several ways you can help yourself if you have been diagnosed with stress incontinence.

    • If you need to lose excess weight, try to do so with regular exercise and eating healthily. Aim to do 150 minutes (two and a half hours) of exercise over a week in bouts of 10 minutes or more. Try low-impact exercises, such as walking or swimming.
    • Brace your pelvic floor before you laugh, cough or sneeze. To do this, imagine that you're trying to stop your urine flow.
    • Cut down on how much caffeine you consume. Caffeine is a diuretic which means it increases the amount of urine your body produces and makes your symptoms worse. It can also irritate your bladder.
    • You may wish to wear absorbent pads to absorb any leaks. You can buy these from pharmacies and some supermarkets.

    Physical therapies

    Your doctor may give you some pelvic floor muscle exercises to do or refer you to a physiotherapist to help you learn these. Exercises to strengthen these muscles will give you more control over when you pass urine. You will need to do these exercises for several months. For information about pelvic floor exercises, see FAQs.

    If you're not sure whether you're exercising the right muscles, ask your doctor for help. If you're having difficulty, they may suggest you try biofeedback techniques. Biofeedback therapy uses a computer and electronic instruments to tell you when you're using the right pelvic floor muscles.

    If you’re a woman, your doctor might recommend you use vaginal cones. These are weights that you hold in your vagina to help you strengthen your pelvic floor.

    Medicines

    Your doctor may prescribe you a medicine called duloxetine. This will increase the activity of the nerve that stimulates your urethral sphincter and will improve how well it works to prevent leaks. Duloxetine isn’t suitable for everyone, as there are side-effects. Always ask your doctor for advice and read the patient information leaflet that comes with your medicine.

    If your stress incontinence is caused by a lack of oestrogen (in women), you may be prescribed an oestrogen cream or oestrogen tablets. You insert the tablets into your vagina.

    Non-surgical treatments

    Some people find that neuromuscular stimulation of the pelvic floor is helpful. In this treatment, your doctor will place a probe into your vagina (if you're a woman) or your rectum (if you're a man). The probe has an electrical current that can help to exercise and strengthen your pelvic floor muscles.

    Injections of bulk-forming agents, such as collagen, around your urethra have been used to treat stress incontinence in the past. They help to keep your urethra closed and reduce urine leakage. They aren’t used very much now because the effect doesn't last long. If you do have injections, you will probably need to have a number of them.

    Surgery

    If other treatments haven’t worked, your doctor might recommend that you have surgery to strengthen or tighten the tissues around your urethra. In women, surgery may not be suitable if you plan to have children in the future – ask your surgeon for information.

    Surgical options include the following.

    • Tension-free vaginal tape – for women only. During this procedure, your surgeon will make a small cut in the wall of your vagina, under your urethra. He or she will then insert a mesh tape between your vagina and urethra. This will support your urethra and stop leaks should your bladder come under any sudden pressure.
    • Sling procedures – for both men and women. A sling is a piece of human or animal tissue or a synthetic tape that will support your bladder neck and urethra. This is more commonly done in women but can also be successful in men (using a different type of sling). However, it’s not suitable for men who have severe incontinence.
    • Burch colposuspension – for women only. In open colposuspension, your surgeon will make a cut in your abdomen (tummy) and lift the tissues around the junction between your bladder and urethra. Your surgeon will then stitch the lower part of the front of your vagina to a ligament behind your pubic bone to help prevent leaks. It may be possible to have keyhole surgery – ask your surgeon if this is an option for you.
    • Artificial urinary sphincter – for both men and women. If your urinary sphincter doesn’t close fully, it may be possible to replace it with an artificial one. Your surgeon will implant it around the neck of your bladder. A fluid-filled ring (called a cuff) will keep your urinary sphincter shut tight until you're ready to pass urine. You then press a valve that's implanted under your skin to deflate the ring and this enables you to urinate. You will usually only be offered an artificial sphincter if other treatments have failed or aren't suitable for you.
  • Stress incontinence treatment on demand

    You can access a range of our health and wellbeing services on a pay-as-you-go basis, including stress incontinence treatment.

  • Causes Causes of stress incontinence

    Stress incontinence usually develops if the muscles in your pelvic floor or urethral sphincter are damaged or weakened. Your pelvic floor is made up of layers of muscles. These form a sling that passes from your coccyx (tip of your spine) to your pubic bone. Your pelvic floor supports your bladder, bowel and, in women, uterus (womb), and forms the floor of your pelvis. Both men and women have a pelvic floor.

    There are a number of things that can make you more likely to develop stress incontinence. For women, these can include the following.

    • Pregnancy. The extra weight from your baby and hormonal changes that happen during pregnancy can weaken your pelvic floor or urethral sphincter.
    • Childbirth. Your pelvic floor muscles can be stretched during a vaginal or caesarean delivery.
    • The menopause. You have less of a hormone called oestrogen in your body after you have gone through the menopause. This can weaken your pelvic floor and urethral sphincter.
    • hysterectomy or another operation in your pelvic area. This can damage your pelvic floor muscles.

    Men can develop stress incontinence after having prostate surgery. The urethral sphincter is close to the top of the prostate and it can be damaged during the operation.

    Other factors that increase your risk of developing stress incontinence (in both men and women) include:

    • having constipation – people with constipation often have stress incontinence too
    • having a persistent cough – this can increase pressure on your bladder
    • age – your muscles weaken as you get older
    • being overweight or obese – extra weight increases the pressure on your bladder and pelvic tissues
    • smoking – this can make incontinence worse, particularly if you smoke more than 20 cigarettes a day
    • surgery or an injury to your pelvis – this may affect your nerves and the function of your urethral sphincter
  • FAQs FAQs

    I have stress incontinence. What things can I do on a daily basis to help me feel better?

    Answer

    Stress incontinence can potentially affect your confidence, relationships, work and social life. However, there are things you can do to help reduce the impact it has on you.

    Explanation

    Some people feel embarrassed about having a bladder problem and try to cope on their own. They may avoid going out, carry extra clothes or wear absorbent pads. However, there are better ways to manage incontinence and effective treatments are available. If stress incontinence is affecting your day-to-day life, speak to your GP. For most people, simple changes to lifestyle or certain treatments can help reduce or stop unintentional leaks.

    There are many things you can do to help you feel more confident and in control. These include the following.

    • If you’re overweight or obese, lose excess weight. Being overweight can make your stress incontinence worse because there is extra pressure on your pelvic floor muscles. Exercise regularly and eat a balanced diet to help you lose weight. Try to do 150 minutes (two and a half hours) of moderate-intensity exercise over a week. You can do this by carrying out 30 minutes on at least five days each week. Try low-impact exercises that still raise your heart rate, such as walking or swimming.
    • Eat plenty of fruit and vegetables, and other foods that contain fibre, such as wholegrain bread and wholegrain cereals. This will help to prevent constipation, which can make your stress incontinence worse.
    • Try not to have too many caffeinated drinks or foods that contain caffeine. Caffeine is a diuretic, which causes your body to lose water by increasing the amount of urine the kidneys produce. It’s also a bladder stimulant, meaning that it can cause you to need to urinate suddenly.

    What is bladder training?

    Answer

    Bladder training involves relearning how to urinate and helps overcome bladder problems, such as incontinence. Your GP may recommend bladder training alone or in combination with other therapies. It’s most often used by women with urge incontinence, however, it may also be helpful for stress and mixed incontinence too.

    Explanation

    Bladder training helps you to return to a normal pattern of urinating by gradually increasing the intervals you leave each time you go to the toilet. Bladder training can help you learn to empty your bladder more completely and how to control urges to urinate.

    A bladder diary may help you identify habits and patterns. Record the number of times that you go to the toilet, how long you can wait between visits and what you drink. From your diary, you will be able to identify how long you can hold your bladder before you need to go to the toilet. You can then set goals to help your bladder become stronger.

    You could start by trying to hold your bladder for 15 minutes every time you feel an urge to go to the toilet. The aim is to lengthen the time between toilet visits until you're going every three to four hours.

    There are several things that can help increase the success of bladder training. These include the following.

    • Make sure your retraining schedule is realistic and set yourself achievable goals. Try to go to the toilet at regular timed intervals and, as you gain control, you can extend the time between visits.
    • Focus on success and not on any setbacks that you may have.
    • Don't drink anything two hours before you go to bed.
    • If you’re worried about having an accident while you’re bladder training, wear absorbent pads to absorb any leaks.
    • Remember that bladder training takes time and determination. Improvements won’t happen overnight but it can be very successful if you do it properly and stick to your schedule.

    If you don't notice any improvement after two to three weeks, contact your GP. You may have another condition that is causing your incontinence, such as a urine infection or damage to your bladder.

    What are pelvic floor exercises and how do I do them?

    Answer

    Your pelvic floor is made up of layers of muscles that support your bladder, bowel and, in women, uterus (womb). Pelvic floor exercises strengthen your urethral sphincter, which is a group of muscles that surrounds your urethra and keeps urine in your bladder.

    Explanation

    Pelvic floor muscles can help you control urinating.  You can use them in situations that may cause you to leak, for example, when you cough or sneeze. Pelvic floor exercises (also known as Kegel exercises) involve repeatedly tensing and relaxing your pelvic floor muscles many times a day.

    We’ve put together some instructions to explain how to do pelvic floor muscle exercises.

    • The first step is to find the right muscles. One way is to imagine stopping yourself from passing urine or wind. It should feel like a ‘squeeze and lift’ inside.
    • Squeeze and lift for 10 seconds as strongly as you can. Rest for 10 seconds and repeat 10 times. Follow this with 10 fast squeezes.
    • Make sure you breathe normally as you do the exercises.
    • Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs or buttocks.
    • You can do the exercises while you're standing, sitting or lying down.
    • Build up your routine, aiming towards doing these exercises three times a day.

    Talk to your GP if you’re not sure whether you’re contracting the right muscles. He or she may examine you while you try to do them or suggest you try biofeedback techniques. This uses a computer and electronic instruments to tell you when you're using your pelvic floor muscles.

  • Resources Resources

    Further information

    Sources

    • Urinary incontinence. National Institute for Health and Care Excellence (NICE), September 2013. www.nice.org.uk
    • Urinary incontinence. PatientPlus. www.patient.co.uk/patientplus.asp, published 25 November 2013
    • Stress incontinence. BMJ Clinical Evidence. www.clinicalevidence.bmj.com, published 14 April 2009
    • Urinary incontinence. Medscape. www.emedicine.medscape.com, published 2 May 2014
    • Urinary incontinence in women. Evidence-based medicine guidelines. www.ebm-guidelines.com, published 17 December 2013
    • Urinary incontinence relevant anatomy. Medscape. www.emedicine.medscape.com, published 7 November 2013
    • Guidelines on urinary incontinence. European Association of Urology. www.uroweb.org, published April 2014
    • Map of Medicine. Female urinary incontinence. International View. London: Map of Medicine; 2014 (Issue 2)
    • Incontinence of urine. British Association of Urological Surgeons. www.baus.org.uk, published 13 May 2014
    • The urinary tract and how it works. National Kidney and Urologic Diseases Information Clearinghouse. www.kidney.niddk.nih.gov, published December 2013
    • Physical activity: brief advice for adults in primary care. National Institute for Health and Care Excellence (NICE), May 2013. www.nice.org.uk
    • Incontinence. Chartered Society of Physiotherapy. www.csp.org.uk, accessed 13 May 2014
    • Herbison GP, Dean N. Weighted vaginal cones for urinary incontinence. Cochrane Database of Systematic Reviews 2013, Issue 7. doi:10.1002/14651858.CD002114.pub2
    • Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com, accessed 13 May 2014
    • Cody JD, Jacobs ML, Richardson K, et al. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database of Systematic Reviews 2012, Issue 10. doi:10.1002/14651858.CD001405.pub3
    • Berghmans B, Hendriks E, Bernards A, et al. Electrical stimulation with non-implanted electrodes for urinary incontinence in men. Cochrane Database of Systematic Reviews 2013, Issue 6. doi:10.1002/14651858.CD001202.pub5
    • Injectable bulking agents for incontinence. Medscape. www.emedicine.medscape.com, published 8 November 2013
    • Stress urinary incontinence. International Urogynecological Association. www.iuga.org, published 2011
    • Single-incision sub-urethral short tape insertion for stress urinary incontinence in women. National Institute for Health and Care Excellence (NICE), May 2008. www.nice.org.uk
    • Insertion of biological slings for stress urinary incontinence in women. National Institute for Health and Care Excellence (NICE), January 2006. www.nice.org.uk
    • Lapitan MCM, Cody JD. Open retropubic colposuspension for urinary incontinence in women. Cochrane Database of Systematic Reviews 2012, Issue 6. doi:10.1002/14651858.CD002912.pub5
    • Artificial urinary sphincter placement. Medscape. www.emedicine.medscape.com, published 4 February 2014
    • Pelvic floor exercises. International Urogynecological Association. www.iuga.org, published 2011
    • Pelvic floor exercises in women. British Association of Urological Surgeons. www.baus.org.uk, published March 2014
    • Bladder training. British Association of Urological Surgeons. www.baus.org.uk, published July 2014
    • Bladder training. International Urogynecological Association. www.iuga.org, published 2011
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