If you have stress incontinence, small amounts of urine leak from your bladder when it’s under sudden, unexpected pressure. This can be from laughing, coughing, sneezing, walking, exercising, lifting a heavy object or from changing position, for example, sitting to standing. Carrying out any movement that suddenly increases the pressure on your bladder can cause uncontrollable loss of small amounts of urine.
To diagnose stress incontinence, your GP will first ask you about your symptoms and medical history. He or she may ask you to keep a ‘bladder diary’ for at least three days. This involves recording how much you drink, when you pass urine, the amount of urine you produce, whether you had an urge to urinate and the number of times you unintentionally leak.
Your GP will usually do a test on a sample of your urine to check that your incontinence isn’t being caused by an infection in your urinary tract – this consists of your kidneys, two ureters (the tubes that connect each kidney to your bladder), your bladder and your urethra. He or she may also do a blood test to check that your kidneys are working properly.
Your GP may examine you. He or she might simply check for loss of urine while you cough or strain. A rectal (back passage) examination will check if you’re constipated or whether the nerves to your bladder are damaged. In men, a rectal examination will determine if the prostate is enlarged. If you’re a woman, your GP will check for weakness of your pelvic floor and look for a prolapse – this is when organs near your vagina, such as your womb, bowel or bladder, slip down from their normal position.
You may be referred to a urologist (a doctor who specialises in identifying and treating conditions that affect the urinary system) or, if you're a woman, a gynaecologist (a doctor who specialises in women’s reproductive health) or urogynaecologist (a doctor who focuses on 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 the kidneys, bladder and urethra. It's most commonly used to check that your bladder is emptying properly.
- Cystoscopy. A procedure used to look inside your bladder and urinary system using a flexible viewing tube. This can identify abnormalities that may be causing the incontinence.
- Urodynamic testing. These techniques measure the pressure in your bladder and the flow of urine. A thin, flexible tube, called a catheter, is inserted into your bladder through your urethra. Water is then passed through the catheter and the pressure in your bladder is recorded.
There are several ways you can help yourself if you have been diagnosed with stress incontinence.
Being overweight or obese can make your stress incontinence worse because there is extra pressure on your pelvic floor muscles. Exercising and eating healthily can help you to lose excess weight. Try to do 150 minutes (two and a half hours) of moderate exercise over a week. You can do this by carrying out 30 minutes on at least five days each week. Do low-impact exercises, such as walking or swimming. High-impact exercise, such as running or sports involving jumping, can increase the pressure on your bladder and cause you to leak.
Drink enough fluid. Cutting down the amount you drink makes your urine more concentrated and it’s likely to make your stress incontinence worse. Try to drink six to eight glasses of fluid regularly throughout the day. Passing urine frequently to prevent having a full bladder can also help.
Other things you can do to help yourself include the following.
- Brace your pelvic floor before you laugh, cough or sneeze – to do this, imagine that you're trying to stop your urine flow.
- Try not to have too much caffeine – caffeine is a diuretic (which causes your body to lose water by increasing the amount of urine your kidneys produce) and a bladder stimulant, meaning that it can cause you to need to urinate suddenly.
- Wearg absorbent pads to absorb any leaks – you can buy these from pharmacies and some supermarkets
Your GP will usually ask you to do pelvic floor muscle exercises (Kegel exercises). These exercises, if done correctly, strengthen your urethral sphincter and pelvic floor muscles to help you control urinating. To do pelvic floor muscle exercises, squeeze the muscles you would use to stop urinating and hold for a count of three. Your GP will recommend that you do these exercises frequently for several months. For more information, see FAQs.
Ask your GP for help if you're not sure whether you're exercising the right muscles. He or she may suggest trying 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 GP might recommend vaginal cones. These are weights that you hold in your vagina that help you strengthen the pelvic floor.
Your GP may prescribe you a medicine called duloxetine. This medicine increases the activity of the nerve that stimulates the urethral sphincter to improve how well it works and prevent leaks. Duloxetine isn’t suitable for everyone, as there are side-effects, so always ask your GP for advice and read the patient information leaflet that comes with your medicine.
If you’re a woman and your stress incontinence is being caused by a lack of oestrogen, your GP might prescribe you an oestrogen cream or oestrogen tablets to insert into your vagina.
Some people might find that neuromuscular stimulation of the pelvic floor is helpful. This is suitable for both men and women. A probe is placed into the vagina (for women) or rectum (for men). The probe has an electrical current that can help to exercise and strengthen the pelvic floor muscles.
Injections of bulk-forming agents, such as collagen, around your urethra can be effective. This helps keep your urethra closed and reduces urine leakage. The procedure is usually done by a urological specialist and takes around five minutes, although you will probably need to have repeat injections. You will have a local anaesthetic for this treatment – this completely blocks pain from the area and you will stay awake during the procedure.
If you have severe stress incontinence and other treatments haven’t been effective, your GP might recommend that you have surgery to strengthen or tighten the tissues around your urethra. As with every procedure, there are some risks associated with having surgery for bladder problems. Talk to your GP or surgeon about your surgical options and the risks that are associated with each one.
Surgical options include the following.
- Tension-free vaginal tape – for women only. During this procedure, your surgeon will make a small incision in the wall of your vagina. He or she will then insert a mesh tape into the incision, which lies between the vagina and the urethra. This supports the middle of the urethra and stops any leaks when your bladder comes under any sudden pressure. The procedure may be done under general or local anaesthetic, depending on medical factors. A general anaesthetic means you will be asleep during the procedure. Tension-free vaginal tape isn’t suitable for all women, especially if you’re considering having children.
- Sling procedures – for both men and women. A sling is a piece of human or animal tissue, or a synthetic tape that your surgeon places to support your bladder neck and urethra. This is more commonly done in women. There is a simpler type of sling implant that has been invented for men, which is usually very successful. However, it’s not suitable for men who have total incontinence or after radiotherapy.
- Burch colposuspension – for women only. Your surgeon will make a large cut in your abdomen (tummy) and lift the bladder neck upwards. He or she will then sew the lower part of the front of your vagina to a ligament behind the pubic bone to help prevent leaks. This operation requires a general anaesthetic and you will probably need to stay overnight in hospital.
- Artificial urinary sphincter – for both men and women. If your urinary sphincter doesn’t close fully, it may be possible to have it replaced with an artificial one. This is implanted around the neck of your bladder and a fluid-filled ring (called a cuff) keeps your urinary sphincter shut tight until you're ready to pass urine. You then press a valve that is implanted under your skin to deflate the ring and allow you to urinate.
Stress incontinence usually develops when the muscles in the pelvic floor or urethral sphincter have been damaged or weakened. Your pelvic floor is made up of layers of muscles that form a sling passing from your coccyx (tip of your spine) to your pubic bone. It supports the bladder, bowel and uterus (womb), and forms the floor of the pelvis. Both men and women have a pelvic floor.
There are a number of factors that make you more likely to develop stress incontinence. For women, these can include the following.
- Pregnancy. Your pelvic floor or urethral sphincter can be weakened because of the extra weight and hormonal changes.
- Childbirth, especially if it takes a long time, your baby is large or you need to have forceps or a ventouse (a type of vacuum pump) during the birth.
- Muscle tearing during childbirth or episiotomies (where the muscle is cut to allow an easier birth).
- The menopause. If you’re postmenopausal, you will have less oestrogen in your body, which can weaken your pelvic floor and urethral sphincter. The urethra shortens and its lining becomes thinner as the level of oestrogen declines during menopause. These changes reduce the urethral sphincter’s ability to close tightly.
- A hysterectomy or other bladder operations can damage your muscles.
Men can develop stress incontinence as a result of prostate surgery. The urethral sphincter is close to the top of the prostate and may be slightly injured when the prostate is removed.
Other factors that increase the likelihood of developing stress incontinence in both men and women include:
- being constipated for a long time
- having a persistent cough
- age – your muscles weaken as you get older
- being overweight or obese – extra weight increases the pressure on your bladder and pelvic tissues
I have stress incontinence. What things can I do on a daily basis to help me feel better?
Having stress incontinence can affect your confidence, relationships, work and social life. However, there are many things you can do to help you feel better day to day.
If you feel embarrassed about having a bladder problem, you may try to cope on your own by not going out, carrying extra clothes or wearing 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, including 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. Exercising regularly and eating a balanced diet can help you lose weight. Try to do 150 minutes (two and a half hours) of moderate exercise over a week. You can do this by carrying out 30 minutes on at least five days each week. Try low-impact exercises, such as walking or swimming.
- Eat plenty of fruit and vegetables, and other foods containing fibre, such as wholegrain bread and wholegrain cereals. This will help stop you from becoming constipated, which can make your stress incontinence worse.
- Try to drink six to eight glasses of fluid regularly throughout the day. Don’t cut down on the amount you drink – cutting back can make your urine more concentrated and is likely to make your stress incontinence worse.
- Try not to drink too much coffee or tea – caffeine is a diuretic, which causes the 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 are pelvic floor exercises and how do I do them?
Your pelvic floor is made up of layers of muscles that support your bladder, bowel and uterus (womb). Pelvic floor exercises strengthen your urethral sphincter (a group of muscles that surrounds your urethra and keeps urine in your bladder) and pelvic floor muscles to help you control urinating. The exercises involve repeatedly tensing and relaxing your pelvic floor muscles many times a day.
Pelvic floor muscle exercises build up the strength of your pelvic floor muscles and teach you to use them in situations that may cause you to leak, for example, when you cough or sneeze.
The following instructions explain how to do pelvic floor muscle exercises.
- The first step is to find the right muscles. One way to find them 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.
You might find it easier to begin doing your pelvic muscle exercises lying down. This is because your muscles don’t need to work against gravity. You can then do your exercises sitting or standing up when your muscles get stronger.
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 trying biofeedback techniques. Biofeedback therapy uses a computer and electronic instruments to tell you when you're using the right pelvic floor muscles.
What is bladder training?
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 used for stress and mixed incontinence.
Bladder training helps you to return to a normal pattern of urinating by gradually increasing the time between passing urine. Bladder training can help you learn to empty your bladder more completely and how to control urges to urinate. Bladder training is more appropriate for urge incontinence than for stress incontinence.
To help identify your bladder habits and patterns, start a bladder diary. Record the number of times that you pass urine, how long you can wait until you need to urinate and what you drink. From your diary, you will be able to identify how long you can hold your bladder for before you need to urinate. You can then set goals to help your bladder become stronger.
You could start by trying to hold your bladder for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between passing urine until you're urinating every two to four hours.
There are several things that can help make your bladder training successful, including the following.
- Make sure your retraining schedule is realistic and set yourself achievable goals – try to urinate at regular timed intervals and as you gain control, you can extend the time between passing urine.
- Focus on success and not on any setbacks that you may have.
- Empty your bladder before you go to bed and try to resist any further urges to pass urine before you go to sleep.
- If you’re worried about having an accident while you’re bladder training, you could 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 feel there isn’t 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.
- Incontinence. Chartered Society of Physiotherapy. www.csp.org.uk, accessed 3 November 2011
- Stress urinary incontinence. The Bladder and Bowel Foundation. www.bladderandbowelfoundation.org, accessed 3 November 2011
- Urinary incontinence. The Merck Manuals. www.merckmanuals.com, published October 2007
- Urinary incontinence in women. National Institute of Diabetes and Digestive and Kidney Diseases. www.kidney.niddk.nih.gov, published September 2010
- Urinary incontinence in women. BMJ Best Practice. www.bestpractice.bmj.com, published April 2011
- Personal communication, Mr Raj Persad, Consultant Urologist, Bristol Royal Infirmary, 5 December 2011
- Stress urinary incontinence treatments. The Bladder and Bowel Foundation. www.bladderandbowelfoundation.org, accessed 7 November 2011
- Start active, stay active: a report on physical activity from the four home countries’ Chief Medical Officers. Department of Health, 2001. www.dh.gov.uk
- Urinary incontinence treatment and management. eMedicine. www.emedicine.medscape.com, published October 2011
- Artificial urinary sphincter placement. eMedicine. www.emedicine.medscape.com, published May 2011
- Pubovaginal sling procedures. eMedicine. www.emedicine.medscape.com, published October 2011.
- Personal training for your pelvic floor muscles. The Chartered Society of Physiotherapy. www.csp.org.uk, published April 2011
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