Make me laugh - an overview of stress incontinence

Stress urinary incontinence (SUI) is defined as the leakage of urine when you sneeze, laugh, cough or exert yourself (when exercising, or getting up from a chair, for example). SUI is not caused by or linked to emotional stress or worry.
SUI can affect men and women of all ages, although it is more common among women. It is estimated that around a third of women in the UK have stress incontinence1 - so if you do have SUI, you are by no means alone.
The good news is that most people with this problem can be helped and many people can be cured. The treatments available to treat SUI range from pelvic floor exercises (see below) and medication to surgery.

Why have I got SUI?

The pelvic floor is made up of layers of muscles which hold the bladder and bowel in place and help to stop leaks. The sphincter is a circular muscle that goes around the urethra (the tube that urine comes out of) and squeezes as the bladder fills up to create a seal so that urine can't leak out. If the pelvic floor muscles or sphincter muscles are weak or damaged, you might develop SUI.
In women, these muscles can be weakened during pregnancy by the extra weight and natural hormonal changes. Childbirth can cause more problems, possibly if the second stage of labour is long, the baby is large, or if forceps are used.
Many women have some leakage of urine during pregnancy but most bladder problems get better after delivery. Pelvic floor exercises can help with these problems. Some women develop stress incontinence after the menopause because the level of oestrogen in the body decreases. This can affect the closing of the urethra, leading to stress incontinence. Even before the menopause, some women may notice that stress incontinence becomes worse before a period.
People who have had constipation for a long time, or a bad cough, may also be prone to SUI. Men can develop SUI after a prostate operation.

What can I do about the problem?

The first thing to do is talk to your doctor, nurse or continence advisor (we can provide you with the number of your local continence advisor). The doctor, nurse or continence advisor will assess you and may ask you questions like:

• How often do you go to the loo?
• How often do you leak or have an accident?
• When do you leak or have accidents?
• Is it painful or uncomfortable when you go to the loo?
• How long have you been leaking for?
• How are you managing the leakage at the moment?

The treatment options you might be offered include:

Lifestyle Changes

Healthy drinking habits
It is important to drink enough. Your continence advisor can tell you how much you should be drinking each day.
It is best not to drink too much tea, coffee, cola or fizzy drinks - these can irritate the bladder and make your problems worse. Alcoholic drinks can irritate the bladder too. Drink plain water, fruit juice, fruit or herbal tea and cordials, but avoid blackcurrant as it is acidic. If you pay attention to what you drink you will notice which drinks cause problems and you can try and eliminate them from your diet.
Drinking one or two glasses of cranberry juice every day can help people who often get urine infections - although diabetics should check with their doctor first. The acid in fruit juices can make problems worse for some people - check with your doctor or continence advisor if you are unsure.
Do not cut down the amount you drink - this makes your urine even more concentrated and can make bladder problems worse.

Avoid getting constipated - eat a healthy diet
When the bowel does not empty it swells up and pushes on the bladder.

Try to keep your weight down
Being overweight can put extra pressure on your bladder.

Give Up Smoking
A persistent smoker's cough can make stress incontinence worse.

Pelvic floor exercises
Pelvic floor exercises can help strengthen the muscles in the pelvic floor, giving you more control over your bladder and helping to prevent leaks.
To locate your pelvic floor muscles, imagine that you are trying to prevent yourself from passing wind. To do this you must squeeze the muscle around the back passage. You should be able to feel the muscle move. This is the back part of the pelvic floor.
Now imagine you are about to pass urine - picture yourself trying to stop the stream of urine. This is the front part of the pelvic floor.
To exercise these muscles, you pull them up and hold them, taking turns to do it quickly and then slowly. It is important to learn to do the exercises correctly - talk to your continence advisor or physiotherapist who will be able to tell you how many to do.

Medication
The first ever medication for the treatment of SUI has been developed. Called duloxetine (Yentreve), the drug increases the activity of the nerve that stimulates the urethral sphincter, improving its function. The treatment has been proven to reduce the frequency of episodes with corresponding improvements in quality of life. The main side effect is nausea which may be effectively managed with symptoms subsiding over time.
There are also reports that there are added benefits of using duloxetine in combination with pelvic floor muscle training.

Electrical stimulation
Some people can be helped by electrical stimulation of the pelvic floor. A probe is placed in the vagina (for women) or back passage (for men). The probe carries electrical currents which can strengthen the pelvic floor muscles. This is very useful for people who find it hard to do pelvic floor exercises in the normal way.
This treatment is normally carried out under the supervision of a continence advisor or physiotherapist, although machines are available for you to treat yourself at home. Talk to your continence advisor or physiotherapist to find out more.

Injectables

A less invasive treatment option and an alternative to major surgery, bulking agentscan be injected into the wall of the urethra to improve the sealing mechanism of the bladder. There are a number of options to choose from, some with better results than others.

Teflon, collagen and silicone have all been used to treat bladder weakness with limited success due to the skill requirements of the procedure. Although the procedure is short and can sometimes be done under local anaesthetic, more often, it has to be carried out under general anaesthetic and the substances used have been linked to various drawbacks including allergic reactions and tissue damage.

Botox injections used to reduce wrinkles can also be used to treat people with bladder problems. Botox is injected in the bladder wall and can help those with an overactive bladder. This is a different type of treatment to that of the injections outlined above.  Botox does not bulk-up the sphincter, but stops the bladder itself from contracting so often.

Sometimes, fat from the woman herself can also be used as an injectable treatment. This reduces the risk of infection, but the results are not long-lasting.

A new form of injectable treatment is implacement therapy with Zuidex. It is a new treatment, minimally invasive and has resulted in more than 75 percent of women with SUI being completely cured or experiencing marked improvement1. Zuidex gel is placed along the urethral wall in order to achieve better closure and help prevent urine leakage. The treatment takes 15-20 minutes in an outpatient clinic and involves no hospital stay or lengthy recovery period. Benefits can be seen in just two to three days. Zuidex can be offered to women where pelvic floor exercises have failed or to those who are reluctant to have surgery or who are planning to have more children2. It is also suitable for women who want to try other options prior to surgery, as Zuidex does not rule out the possibility of surgical treatment at a later date¹.

Ref:

• Van Kerrebroeck P, ter Meulen F, Farrelly E et al. Treatment of stress urinary incontinence: recent developments in the role of urethral injection. Urol Res 2003;30:356-62
• Robinson D, Anders K, Cardozo L, et al.� What do women want? Interpretation of the concept of cure.� Journal of Pelvic Medicine and Surgery 2003; 9:273-7

As with all injectable treatments, the results are not permanent and effectiveness is lessened over time. Top-ups may be required but this varies from individual to individual. Some women continue to show good results with injectable treatments after three years. Your healthcare professional can run through the different substances available and help you to decide whether this method is right for you.
Surgery
Surgery should be considered as a last resort. Whatever your particular condition, it is important to really think through the pros and cons of having surgery. Ask your doctor as many questions as you want, and never be afraid to go back or telephone to get more information or a clearer explanation.

Colpo-suspension
A common operation to treat stress incontinence is called a colpo-suspension. This is a major operation that requires a general anaesthetic. The abdomen is opened and the bladder neck is stitched to a nearby ligament. This lifts up the bladder neck and helps to stop leaks from it.

There are two versions of the operation. Open colpo-suspension gives better long-term success rates, but involves making a large cut in the abdomen. Laproscopic colpo-suspension involves making a smaller cut to do the operation - sometimes called keyhole surgery.

This operation can cause extra problems like:

• problems with emptying the bladder (some people need to use catheters after the operation)

• irritable bladder and urgency
• pain during sexual intercourse

Tension-free vaginal tape (TVT)
Tension-free vaginal tape (TVT) is a relatively new operation for women with stress incontinence. It is usually not suitable for those with neurological disease, for women who have not had their menopause yet or are considering further children, or for women with other conditions like a cystocele or vaginal prolapse.

The operation is gaining popularity because of its relative simplicity and cost-effectiveness. The procedure can be done as day surgery, with only a local anaesthetic. Recovery time after the operation is less than some operations for this problem. However it should still not be considered a minor procedure.

The tape is inserted through two vaginal incisions. It runs between the vagina and the urethra, lifting the middle of the urethra. This support can reduce the effect of sudden abdominal stress - the cause of stress incontinence.

There can be problems associated with this operation:

• bleeding
• bladder injury
• difficulty emptying the bladder
• urgency
• urinary infection
• tape erosion
• damage to the bowel or local blood vessels

The operation is still fairly new so long-term success rates and side-effects are not known.
As with all treatments, this operation has its advantages and its risks. We have a detailed factsheet outlining the operations available to help people with SUI - contact us for a copy.
Your doctor or continence advisor will discuss with you what any operation involves, but remember to ask if you are unsure about anything.

1. Hunskaar S, Lose G, Sykes D, Voss S. 'The prevalence of urinary incontinence in women in four European countries', British Journal of Urology International, February 2003

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