Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise.

The ability to hold urine and control urination depends on the normal function of the lower urinary tract, the kidneys, and the nervous system. You must also have the ability to recognize and respond to the urge to urinate.

Stress incontinence is a bladder storage problem in which the strength of the muscles (urethral sphincter) that help control urination is reduced. The sphincter is not able to prevent urine flow when there is increased pressure from the abdomen.

Stress incontinence may occur as a result of weakened pelvic muscles that support the bladder and urethra or because of a malfunction of the urethral sphincter. The weakness may be caused by:

• Brain or nervous system (neurological) injury
• Injury to the urethral area
• Some medications
• Surgery of the prostate or pelvic area

Stress urinary incontinence is the most common type of urinary incontinence in women.

Stress incontinence is often seen in women who have had multiple pregnancies and vaginal childbirths, and whose bladder, urethra, or rectal wall stick out into the vagina (pelvic prolapse).

Risk factors for stress incontinence include:

• Being female
• Childbirth
• Chronic coughing (such as chronic bronchitis and asthma)
• Getting older
• Obesity
• Smoking

Involuntary loss of urine is the main symptom. It may occur when:

• Coughing
• Sneezing
• Standing
• Exercising
• Engaging in other physical activity

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 reveal that the bladder or urethra is bulging into the vaginal space.

Tests may include:

• Inspection of the inside of the bladder (cystoscopy)
• Pad test (after placement of a preweighed sanitary pad, the patient is asked to exercise -- following exercise, the pad is reweighed to determine the amount of urine loss)
• Pelvic or abdominal ultrasound
• Post-void residual (PVR) to measure amount of urine left after urination
• Rarely, an electromyogram (EMG) is performed to study muscle activity in the urethra or pelvic floor
• Tests to measure pressure and urine flow (urodynamic studies)
• Urinalysis or urine culture to rule out urinary tract infection
• Urinary stress test (the patient is asked to stand with a full bladder, and then cough)
• X-rays with contrast dye of the kidneys and bladder

The health care provider may also measure the change in the angle of the urethra when at rest and when straining (Q-tip test). An angle change of greater than 30 degrees often means there is significant weakness of the muscles and tissues that support the bladder.

Treatment depends on how severe the symptoms are and how much they interfere with your everyday life.

The doctor may ask that you stop smoking (if you smoke) and avoid caffeinated beverages (such as soda) and alcohol. You may be asked to keep a urinary diary, recording how many times you urinate during the day and night, and how often urinary leaking occurs.

There are four major categories of treatment for stress incontinence:

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

Behavioral changes involve decreasing how many fluids you drink, if you drink too much during the day. (You should not decrease your fluid intake if you drink normal amounts of fluids.)

Urinating more frequently may help some patients decrease the amount of urine that they leak. Constipation can make urinary incontinence worse, so dietary or medical treatments to help keep regular bowel habits are recommended.

Weight loss has been shown to help decrease symptoms in those who are overweight. Some people with severe stress incontinence may change their activity level to avoid movements such as jumping or running, which can cause greater leakage of urine.

Pelvic muscle training exercises (called Kegel exercises) may help control urine leakage. These exercises improve the strength and function of the urethral sphincter.

Some women may use a device called a vaginal cone along with pelvic exercises. The cone is placed into the vagina, and the woman tries to contract the pelvic floor muscles in an effort to hold it in place. The device may be worn for up to 15 minutes. This procedure should be done two times a day. Within 4 - 6 weeks, most women have some improvement in their symptoms.

Biofeedback and electrical stimulation may be helpful for those who have trouble doing pelvic muscle training exercises. These two methods can help you identify the correct muscle group to work. Biofeedback is a method that helps you learn how to control certain involuntary body responses.

Electrical stimulation therapy uses 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 doctor's office or at home.

Treatment sessions usually last 20 minutes and may be done every 1 - 4 days. Newer techniques are being investigated, including one that uses a specially designed electromagnetic chair that causes the pelvic floor muscles to contract when the patient is seated.

Medicines tend to work better in patients with mild to moderate stress incontinence. They include:

• Antimuscarinic drugs block bladder contractions. Many doctors 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 in a similar way to alpha-adrenergic drugs.

Estrogen therapy can be used to improve urinary frequency, urgency, and burning in postmenopausal women. It also can improve the tone and blood supply of the urethral sphincter muscles.

However, whether estrogen treatment improves stress incontinence is controversial. Women with a history of breast or uterine cancer should usually not use estrogen therapy for the treatment of stress urinary incontinence.

Surgical treatment is only recommended after the exact cause of the urinary incontinence has been determined. Different types of surgeries are described below.

COLLAGEN INJECTION

A minor surgical procedure called collagen periurethral injection may be recommended for the treatment of male and female stress incontinence caused by urethral sphincter dysfunction. The collagen makes the area around the urethra thicker, which helps control urine leakage.

This procedure is done in an outpatient setting with a local or spinal anesthesia. The procedure may need to be repeated after a few months to achieve bladder control.

Potential complications include:

• Infection
• Temporary erectile dysfunction in men
• Urine retention

Some people may have a potentially serious allergic reaction to collagen. Any candidate for collagen injection must have an allergy skin test before treatment.

ANTERIOR VAGINAL REPAIR OR PARAVAGINAL REPAIR

These vaginal procedures are often done in women when the bladder is bulging into the vagina. (Such a condition is called a cystocele.) An anterior vaginal repair is done through a surgical cut in the vagina, and a paravaginal repair may be done through a surgical cut in the vagina or abdomen.

In an anterior repair, the supportive tissue between the vagina and bladder is folded and stitched together so the bladder and urethra are in the proper position.

In a paravaginal repair, the supportive tissue between the vagina and bladder is stitched to the tissue covering the pelvic floor muscles, so the bladder and urethra are supported.

Often, these procedures are done along with another procedure for stress incontinence, such as a hysterectomy or retropubic suspension.

NEEDLE BLADDER NECK SUSPENSION

Needle bladder neck procedures use special needles to make a minor cut in the abdomen and vagina. The procedures (Modified Pereyra and Stamey procedure) differ based on the structures that are used to anchor and support the bladder. This type of surgery is only done on women.

Because the success rate tends to be lower than other surgeries, they are not being done as often as they used to be. Possible complications include:

• Fistula (rarely)
• Inability to urinate
• Urge incontinence
• Urinary tract infection
• Wound infection

RETROPUBIC SUSPENSION

Retropubic suspension is used to describe a group of surgical procedures done to lift the bladder and urethra. These procedures are done through a surgical cut in the abdomen. The procedures (Burch colposuspension and Marshall-Marchetti-Krantz -- MMK) differ based on the structures that are used to anchor and support the bladder.

Possible complications include:

• Fistula (rarely)
• Inability to urinate
• Infection
• New urge incontinence
• Urinary tract infection

SLING PROCEDURE

Most doctors who treat incontinence recommend a sling operation as the first choice for the treatment of uncomplicated stress incontinence in women. This procedure is rarely done in men.

A sling is formed by taking a piece of the abdominal tissue (fascia) or synthetic material. The human-made sling pushes on the urethral sphincter, preventing leakage of urine during stressful movements.

These procedures require a small surgical cut in the abdomen and vagina. Many different types of the sling procedure have been developed, including a transvaginal tape procedure which uses smaller cuts and can be done as an outpatient surgery.

Possible complications include:

• Abnormal connection (fistula) or infection (abscess)
• Infection
• Urgency
• Urge incontinence
• Urinary retention
• Wearing away of the sling
• Vaginal wall that doesn't heal

ARTIFICIAL URINARY SPHINCTER

Artificial urinary sphincter is a surgical device used to treat stress incontinence in men. Artificial urinary sphincters are rarely used in women.

Most health care providers tell their patients to try other treatments first. Possible complications include infection and urethral erosion, which requires that the device be removed. You may need to modify some activities (such as bicycle riding) to accommodate the device.

Behavioral changes, pelvic floor exercise therapy, and medication usually improve symptoms rather than cure stress incontinence. Surgery can cure most patients, if they are carefully selected.

Treatment does not work as well in people with:

• Conditions that may prevent healing or make surgery more difficult
• Other genital or urinary problems
• Previous surgical failures

Complications are rare and usually mild. They can include:

• Irritation of the vulva
• Pain during intercourse
• Unpleasant odors
• Vaginal discharge

The condition may affect or disrupt social activities, careers, and relationships.

Call for an appointment with your health care provider if you have symptoms of stress incontinence and they are bothersome.

Performing Kegel exercises (tightening the muscles of the pelvic floor as if trying to stop the urine stream) may help prevent symptoms. Doing Kegel exercises during and after pregnancy can decrease the risk of developing stress urinary incontinence after childbirth.

Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA. 2008;299:1446-1456.

Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med. 2008;358:1029-1036.