Stress Incontinence is a condition resulting from an increase in pressure in the abdomen that increases physical stress on the pelvis causing urine leakage. Coughing, sneezing, laughing, exercise and even standing up are activities that can cause leakage in women with this type of incontinence.
Diagnosis
Incontinence is a common treatable condition. If you have a problem, make an appointment at the UCSF Women's Continence Center. Keep a diary that includes how often you urinate during the day, a record of the times and events surrounding leakage, and what you are drinking. This can help your health care provider make the proper diagnosis and decide on the appropriate treatment.
At your first visit, your UCSF Women's Continence Center provider will do a complete history and physical exam, including a pelvic exam and urinalysis. If your problem is complex, additional tests may be done at a later visit.
Depending on the particular details of your medical history, your doctor may proceed to any or all of the following physical evaluations.
Neurologic examination to evaluate the strength, sensation, and reflexes in your legs.
Pelvic examination to assess pelvic relaxation or prolapse.
Postvoid residual urine assessment will measure how much urine remains in your bladder within 15 minutes of voiding. It offers an estimation of your bladder's ability to efficiently "empty the tank."
Other assessments: At the same time a postvoid residual is checked, the same urine sample may be analyzed for other factors, such as blood, sugar, crystals or signs of infection. Such an evaluation can be accomplished with an office urine dipstick or the hospital laboratory's microscopic urinalysis.
Urine culture: If a urine dipstick or urinalysis suggests signs of acute infection, a urine culture will be sent to the microbiology lab. In approximately 24 to 48 hours, bacterial growth can be detected and the specific strain identified.
Pelvic floor assessment to evaluate the strength of your pelvic floor muscles, and particularly, your ability to contract and relax the appropriate muscle group.
Cough stress test: Your doctor will instill water into your bladder, and then ask you to cough or strain in the same manner that would cause you to leak urine. This test can be performed in the office or incorporated into more elaborate urodynamics testing.
URINARY DIARY: Sometimes details about your fluid intake and urine output are crucial to making the right diagnosis. Because this is not typically the sort of information we take notice of in our daily lives, your provider will give you a bladder diary and a measuring receptacle.
You may be asked to carefully record the time and amount of any fluids you drink and the urine you void over a complete 24-hour period. You may be asked to repeat this 24-hour diary for three to five days. This allows us to notice patterns that might be important to planning your treatment.
When the clinical picture seems less straightforward, or multiple previous therapies have been unsuccessful; your doctor may decide to pursue further diagnostic testing. The purpose of these studies is to evaluate the anatomic and functional status of the bladder and urethra, reproducing your symptoms. Testing may include:
Cystometrogram: Catheters are placed in your bladder and vagina or rectum so that the physician can reproduce your daily urinary symptoms. During the test, fluid will be infused in a controlled fashion to determine various characteristics about your bladder's function, including:
Your perception of water filling the bladder
Any urgency to urinate
Any uncontrollable bladder contractions
The volume at which your bladder cannot comfortably hold any more
The pressures that develop within your bladder during the fluid storage process
Stress testing: You may be asked to perform a number of maneuvers such as coughing, changing positions, or bouncing on your heel with the catheter in place in an effort to reproduce any symptoms of urine leakage or incontinence.
Urethral pressure profile: A catheter in your urethra is manipulated to measure urethral function.
Uroflometry: During urination, a specially devised receptacle will measure the varying rate of urine flow, as well as duration of urination.
Pressure voiding study to identify abnormal voiding patterns or urine obstruction
Other Tests
Cytoscopy: A slender camera is inserted via the urethra into the bladder to enable your doctor to view the interior anatomy of the bladder and urethra. It is typically an outpatient diagnostic procedure performed for the following common symptoms:
Blood or pus in urine with no bacteria present
Bladder infections that are unusually difficult to treat
New onset voiding irritation
New onset bladder pain
Suspected foreign body in the bladder
Urodynamics tests fail to duplicate incontinence symptoms
Radiologic tests identify upper or lower urinary tract structural abnormalities.
Intravenous pyelogram (IVP) involves the administration of intravenous (IV) dye to your bloodstream to obtain X-ray snapshots of the entire urinary tract while the kidneys are processing the injected dye. This test cannot be performed if you have an allergic reaction to IV contrast dye, or abnormal kidney function
CT scan of abdomen and pelvis in which an X-ray machine takes a rapid sequence of two-dimensional thin cross-sections of the body in the area of interest. This exam can be performed with or without contrast dye, depending on what your doctor is looking for. The X-rays provide great detail of most of the internal organs.
Ultrasound doesn't involve X-rays. It uses a skin probe that directs sound waves to bounce off the body's internal organs to produce an anatomic picture. It can be a very useful screening tool.
Treatment
Behavioral therapies, pessaries (vaginal inserts) and surgery are the three treatment options for women with this condition. The objective is to rehabilitate the pelvic floor by building the strength and function of the muscles that support the bladder, urethra and other organs contained within the pelvic region.
Behavioral treatments are simple, self-directed, have no side effects and are often used in conjunction with other treatment options. They have proven effective for many women and work well for certain types of incontinence. They include:
Pelvic muscle exercises: Pelvic muscle exercises, also known as Kegels, can help improve incontinence and prevent it from worsening. They can help you suppress the urge to urinate. The exercises strengthen and tone the muscles that support the pelvic organs. These muscles contract and relax under your command to control the opening and closing of the bladder. When these muscles are weak, urine leakage may occur. To achieve the best results, imagine yourself as an athlete in training. You need to build strength AND endurance of your muscles. This requires commitment and regular exercise. Correct technique also is very important.
Biofeedback: Biofeedback takes information about something happening in the body and presents it in a way that we can see or hear and understand. Getting on a scale to check your weight or having your blood pressure taken are very simple examples of biofeedback. Biofeedback can be used to measure any body response such as heart rate or muscle contraction and relaxation. The measurement can be displayed on a computer screen or heard as a tone and used to learn about a subtle body function.
Biofeedback has been effective in treating urinary incontinence. It can help you learn to control and strengthen your pelvic floor muscles and play an important role in bladder control.
Because you cannot see the pelvic floor muscles, you may find it difficult to locate them. Perhaps you are uncertain if you are doing the exercises correctly. This is where biofeedback can help. Biofeedback therapy uses computer graphs and audible tones to show you the muscles you are exercising. It also allows the therapist to measure your muscle strengthen and individualize your exercise program. It is a teaching tool to help you learn to control and strengthen the pelvic floor area.
Vaginal inserts or pessaries are frequently used to treat bladder and pelvic support problems. A pessary is a vaginal insert, similar to a contraceptive diaphragm, which is placed into the vagina to support the uterus as well as bladder and rectum. It is a firm ring that presses against the wall of the vagina and urethra to help decrease leakage. The type and size of the insert is fitted to address your problem and your body. A properly fitted pessary is not noticeable when in place.
Surgery is performed to restore the position of the bladder neck and urethra. There are two main types of surgical operations: bladder neck suspension procedures and sling procedures. Within the medical community, the comparative effectiveness of these procedures is still being debated, and it is important that your decision is based on your individual circumstance. If you are considering surgery, talk to your doctor about these factors.
Bladder neck suspension procedures involve placing small stitches between the ligaments and tendons that support the pelvic organs and then tying them to the pubic bone to stabilize the bladder and urethra. These procedures can be performed through the vagina with a long needle or through an incision in the stomach. Vaginal bladder neck suspension procedures are performed more often since recovery time is shorter and other pelvic support problems (prolapsed organs) can be corrected at the same time.
Pubovaginal sling procedures use a piece of strong connective tissue from another part of the body, typically from the abdomen, to create a supporting "hammock" underneath the urethra and bladder neck.
Medications. There are currently no medications prescribed specifically for the treatment of stress urinary incontinence. However there are several experimental medications in development. We anticipate that medications for this condition will be available in the near future.
Estrogen replacement therapy taken in pill or skin patch form has NOT been an effective treatment for female urinary incontinence. Vaginal estrogen (creams, vaginal rings or vaginal pellets) is useful for reducing recurrent urinary tract infections in postmenopausal women, but it's effectiveness in treating incontinence is not known.
