This is the leakage of urine caused by coughing, sneezing, laughing, sudden movements, lifting and physical exercise. Some women also leak during sex.

  • How is Stress Incontinence treated? Open or Close

    Lifestyle changes

    1. Lose weight.

    2. Stop smoking.

    3. Avoid chronic straining/treat constipation.

    If you are overweight, losing weight will reduce the pressure on the pelvic floor and can result in improvement of stress urinary incontinence (SUI). Of course there are other general health benefits to weight loss as well.

    Many smokers have chronic coughs which result in bursts of pressure being applied to the pelvic floor causing urine to leak. So stopping smoking can help, in addition to benefiting your health as a whole.

    Some people who suffer with constipation strain to open their bowels which is not good for the pelvic floor. It is therefore important to maintain an adequate fluid intake, as well as eating a healthy, balanced diet containing plenty of fibre. At times it may be appropriate to take a gentle laxative.

    Physiotherapy

    What is the pelvic floor?
    The pelvic floor is the layer of muscles at the base of your pelvis that supports your pelvic organs, bladder, womb and back passage, and controls the passage of urine. The muscle layer forms a hammock or sling from the pubic bone in front to the coccyx (tail bone) behind. These muscles help to prevent urine leaking when coughing, sneezing or straining. Pelvic floor exercises, therefore, are contractions of these muscles. You can increase the strength of these muscles and hence the pelvic floor by regularly exercising these muscles as well as controlling urgency and urge incontinence.

    How to contract the pelvic floor muscles
    This can be done in two ways: imagine you are trying to stop yourself from passing wind. This squeezes the muscle around the back passage. Secondly, imagine that you are trying to stop your urine stream. This tightens the vagina. Do not use your tummy muscles or your bottom. If you are not sure you are exercising the right muscle, put two fingers gently into the vagina and try to squeeze around them.

    To increase the strength of your pelvic floor muscles, you should perform fast and slow exercises.

    Slow exercises
    Sit or stand comfortably with your knees slightly apart. As described above, squeeze your pelvic floor muscles as tight as you can, and hold for as long as you can. Try and hold the contraction for 10 seconds. You may not be able to hold it for more than two or three seconds at first. Repeat this as often as you can, up to ten times, but have a rest in between each one for five seconds.

    Fast exercises
    Fast exercises are done in the same way as slow exercises, but when you squeeze the muscles, let go immediately so that you only feel a very quick lift in your pelvic floor. You should repeat these exercises up to 10 times.

    You should do both fast and slow exercises six times a day.

    Not all women will be able to perform pelvic floor exercises. Those who cannot may benefit from instruction and supervision from a continence advisor or specialist physiotherapist. For those women who cannot contract their pelvic floor muscles, it may be possible to simulate contractions using a special probe. This is called electrical stimulation and is a technique that women can administer themselves following instruction.

    There are alternatives to performing pelvic floor exercises as described above such as biofeedback and vaginal cones.

    Women are often advised to practice contracting their pelvic floor muscles by trying to stop the flow of urine mid-stream. Whilst this is useful to help you identify which muscles you should be contracting, it is not advisable to be doing your exercises this way.

    Drug Treatment

    Yentreve, otherwise known as duloxetine, is the only available drug specifically designed to treat SUI. It may be suitable for women who want to avoid surgery or those who are waiting for surgery. There is no reason why you cannot take it whilst you are working on your pelvic floor muscles. The benefits of drug treatment are usually seen in a few weeks. Like all drugs, you may experience side effects which usually settle with time, but at the end of the day it is a balance between side-effects and the benefits. Yentreve works by increasing the tone of the muscle around the urethra - a sort of chemical physiotherapy if you like. Women usually have to take the treatment indefinitely as symptoms usually return once you stop taking it.

    Although the drugs are effective, their main drawback is side-effects which are more of a nuisance and rarely serious. The drugs work on certain receptors in the nerve endings which make the bladder muscle contract. These receptors are found throughout the body. The drugs are unable to target just those receptors in the bladder, hence the side-effects. The side-effects most commonly reported include dry mouth, heartburn or acid reflux, bloating, headaches and constipation. It is impossible to predict who will get side-effects, but once again treatment is a balance between side effects and the benefits. If one drug does not work or gives you side effects you can try another.

    All the drugs bar one come in tablet form which you take daily. The exception is a patch which is changed twice a week. One of the most commonly prescribed drugs is oxybutynin which comes in both tablet and patch form.

    There are no hard and fast rules as to how long you should take drug treatment, but it is advisable that you should continue therapy for a minimum of two or three months, or at least until your symptoms are under control. Some patients need to be on treatment for much longer. You can then try stopping treatment. If your symptoms return you can restart treatment.

    If drug treatmnent is unsuccessful, you will probably require further investigation such as urodynamics or cystoscopy. Other treatments such as nerve stimulation and injection of botulinum toxin A may need to be considered.

    Surgery for Stress Incontinence

    Many different operations have been described for the treatment of stress urinary incontinence, but of these the most popular ones of late have been insertion of tapes, colposuspension and injection of urethral bulking agents.

    Tension-free vaginal tape (TVT)
    The TVT Procedure
    The TVT (also known as the suburethral or midurethral sling) was developed in the mid-1990s. It has rapidly become the most popular operation to treat stress incontinence. It is not a treatment for urge incontinence or vaginal prolapse.

    Some women who suffer from both stress and urge incontinence may also benefit from the TVT operation. The TVT is appropriate for many types of patient, including those who have had previous surgery for incontinence.

    The tape is synthetic, i.e. man-made. It is placed beneath the middle of the urethra, which is the tube through which you pass urine. A small 1.5cm incision is made in the front wall of the vagina  through which the tape is inserted. The tape is then brought out through two 1cm incisions below the bikini line with the aid of two long needles. The tape acts like a sling or hammock to provide support for the urethra. A fine telescope (cystoscope) is introduced into the bladder to exclude any injury to the bladder and then the tightness of the tape is adjusted. The tape stays in the body and does not dissolve. It is held in place by the body tissues. The vaginal incision is closed with a stitch which dissolves. The two stitches in the bikini line are either closed with a stitch which can be removed after a few days or with glue which washes away in time. The operation takes approximately 20 minutes.

    After returning to the ward, the nurse will monitor how well you pass urine. The vast majority of women are fine and go home the same day of the operation.

    How successful is the operation?
    In our most recent departmental audit, 86.3% of women were cured of stress urinary incontinence following a TVT procedure. An additional 9.1% noticed great improvement in their stress urinary incontinence, but were not completely dry. This left 4.6% who did not benefit from surgery. There are few long term studies. In one long term study where women were followed up for 11 years after surgery, 77% said they were dry and a further 20% significantly improved. Unfortunately, no operation for stress urinary incontinence is 100% successful. Furthermore, the operation is less successful if you are significantly overweight (less than 70% of patients are dry  if their body mass index greater than 35).

    What are the risks of the operation?
    BLEEDING – the risk of significant bleeding is very small. The amount of blood loss during the procedure is small (less than 100ml). To date, in my experience of over 700 operations, no patient has required surgery to control bleeding or required a blood transfusion.

    INFECTION – there is a small risk of a urine infection which can easily be treated with antibiotics. Less common is a vaginal infection. If you have a period, it is advisable to use a sanitary towel rather than a tampon for the first six weeks after surgery.

    DAMAGE TO BLADDER – the risk is about 1-2%. Damage to the bladder may occur despite taking necessary precautions but it is a minor complication. The ‘damage’ is two small punctures (like a tyre puncture) made by the needle which is used to insert the tape. If the bladder is damaged, the tape can still be inserted, but a catheter is left in the bladder for a week for the bladder to rest and heal. You will be discharged home with the catheter in place to return to hospital after one week to have the catheter removed. This type of damage to the bladder does not cause any long term problems.

    DIFFICULTY PASSING URINE – although the tape is inserted with minimal tension, it must be tight enough to stop urine leakage but not too tight to stop you passing urine. However, even in straightforward cases, a small number of women will not be able to empty their bladder properly. Unfortunately it is difficult to predict before surgery who will develop this problem. In the majority of cases, difficulty passing urine is a temporary problem. If this happens to you, there are a number of options. One way is to for you to be taught to self-catheterise several times a day to get rid of the urine that you cannot pass naturally yourself. What happens is that you pass as much urine as you can naturally and then you drain the urine left in your bladder by inserting a short catheter into your bladder through your urethra. The catheter is removed once your bladder has emptied (usually a few seconds) and thrown away. Naturally you will be taught how to self-catheterise. If you do have to catheterise yourself, it is most like to be for no more than a few weeks or months as the problem usually settles down.

    Occasionally, the tape may have to be loosened.

    URINARY URGENCY AND URGE INCONTINENCE – although the operation is not intended to treat urinary urgency or urge incontinence, some women (60% of our patients) report an improvement or complete resolution of these symptoms. In about a third of patients, these symptoms stay as they were before surgery. In 9% of cases, urinary urgency and urge incontinence may get worse following surgery or develop as new problems (1%). However, these symptoms can be treated with tablets and physiotherapy. If you are already taking tablets to control urinary urgency and/or urge incontinence, it is advisable to continue taking those tablets for four to six weeks after surgery.

    TAPE EROSION - if the tape is very close to a surface such as the vaginal skin, the inside of the urethra or bladder, it can, over a period of time can extrude through. This is referred to the tape eroding through or becoming exposed. This is an uncommon complication. I have experienced just one case in over 700 tapes inserted. The commonest place for the tape to become exposed is in the vagina where the exposed portion is usually cut out. A tape that has eroded into the urethra or bladder is more difficult to cut out.

    Like any operation, the benefits of surgery must be weighed up against the risks.

    Do I need and anaesthetic?
    Yes. The type of anaesthesia is usually decided by the surgeon. Mr Matharu’s choice is a general anaesthetic. The alternative is to stay awake during the operation by having the procedure performed under a spinal anaesthetic, in which case you will have a catheter inserted into your bladder in the operating theatre and may have to stay in hospital overnight.

    How long will I stay in hospital?
    Most women will go home either on the same day as their operation or the following day as long as they are passing urine satisfactorily. When you return to the ward after your operation or after your catheter has been removed, you will be advised to pass urine when you get the usual sensation to do so. Immediately after you have passed urine, your bladder will be scanned to see how much urine is left. If the amount is small you may go home. If the amount is large, your bladder will be drained and checked again later.

    A small amount of vaginal bleeding for a week is to be expected. You should report any heavy bleeding. Some women with a prominent or lax front vaginal wall have reported that when they are washing themselves they can feel something rough which they think is the tape, but it is in fact the stitch which will dissolve in a few weeks.

    After the operation, you may find that you pass urine more slowly than you did before surgery. This does not mean that there is a problem. A slow stream may improve over a period of time. If, however, urine is just trickling out, please contact the ward. Similarly, it is not unusual to find that when you get up from the toilet after you have passed urine, you feel the need to pass some more. Simply sit down again and pass the rest. It is not essential that you have to get rid of every drop of urine.

    Is the surgery painful?
    The operation is associated with some pain which is usually well controlled with pain-killing tablets. It is unusual to experience severe pain.

    When can I drive?
    Usually within one week of surgery.

    When can I return to work?
    You may return to work after one or two weeks, unless you have a job which involves regular heavy lifting, which should be avoided for a month.

    When can I start exercising?
    You may start to exercise after four to six weeks. It is advisable to build up to your normal exercise regime gradually.

    When can I have sexual intercourse?
    You can resume intercourse after six weeks. Do not use tampons or insert anything into the vagina before this.

    Can I have more children after the operation?
    Yes you can. However, the success of the operation may not be as high following the pregnancy. Ideally, surgery is best left until after you have completed your family.

    Is there an age limit for the operation?
    No. As long as you are medically fit for surgery, age should not be a barrier as long as you accept the benefits and risks of surgery. The oldest patient that I have operated on was 91 years of age.

    What happens if the tape fails and I become incontinent again?
    Treatment would depend on the type of incontinence and on the severity of the problem. You would probably need further investigations to establish the underlying problem. Further surgery, including insertion of a new tape, may need to be considered.

    Transobturator tape (TOT)
    TVT is the most popular operation for stress urinary incontinence. Soon after its introduction about fifteen years ago, the TVT was modified in order to try and make the procedure safer, in particular to try and reduce the risk of bladder injury. And so the transobturator tape (TOT) was developed. The principle is the same as the TVT and the tape is positioned in the same place, i.e. beneath the middle of the urethra, but the way the tape is inserted is different.

    With the TVT, the tape is inserted by the passage of a needle upwards from the vagina, behind the pubic bone and brought out through two small incisions just below the bikini line. With the TOT, the tape is inserted via the vagina but is brought out through a small incision in each groin. Studies have shown that the TOT is as effective as the TVT, at least in the short term.

    Advantages of TOT
    •    The main advantage is less risk of damage to the bladder.
    •    The TOT is as effective at curing SUI as the TVT.

    Disadvantages of TOT
    •    Some women complain of pain in the groin after insertion of the tape. This usually settles on its own.
    •    Compared to the TVT, there is a greater risk of exposure of the tape in the depressions of the vagina either side of the urethra.

    The other risks of surgery, postoperative recovery, instructions for resumption of work and physical activity are the same as for a TVT.

    Colposuspension
    Colposuspension is one of the operations to treat stress urinary incontinence (SUI). The technique involves stabilising the urethra and it can be performed through a bikini-line incision or via keyhole surgery. Stabilisation of the urethra is achieved by pulling up the front vaginal wall, which is direct contact with the urethra, using stitches. The operation cures the majority of women. In one study, 69% of women who were reviewed 12 to 20 years after surgery were cured.

    Until a few years ago, colposuspension was the most popular operation for treating SUI. The tension-free vaginal tape (TVT) has taken over as the most popular operation mainly because there are fewer risks associated with surgery and the postoperative recovery is much shorter. The main risks of colposuspension are difficulty passing urine afterwards and overactive bladder symptoms developing postoperatively. Other risks include bleeding, infection, damage to the bladder and possibly development of vaginal prolapse in the future. In the short term, colposuspension and TVT appear to be equally effective.

  • When is treatment necessary? Open or Close

    The amount of leakage can vary depending on what triggers it and also from person to person. Similarly, the impact on quality of life and degree of bother varies. Treatment should take into account all these factors and not just the amount that leaks.

    For example, a 35 year old woman who has a small amount of leakage when she goes to the gym three times a week, and a 50 year old who has a huge leak but only when she sneezes, may both have a reduced quality of life, but one is no less deserving of treatment than the other.

  • Can Stress Incontinence be prevented? Open or Close

    There is evidence that antenatal pelvic floor exercises can reduce the risk of developing SUI after childbirth.

  • What causes stress urinary incontinence? Open or Close

    You are at greater risk of developing SUI if you have or have had the following:

    1. Childbirth
    2. Obesity
    3. Chronic cough
    4. Lax joints (double-jointed)
    5. Constipation

    Childbirth
    A vaginal delivery results in damage to the supports of the urethra (the tube through you pass urine) and damage to the nerve supply of the urethral sphincter (and pelvic floor muscles) so the muscle within it cannot contract properly. As a result, the urethra becomes mobile and is too weak to stop urine from escaping. Interestingly, avoiding vaginal delivery by having a planned caesarean section does not guarantee SUI developing, although the risk is smaller.

    Obesity
    If you are obese there is greater pressure on your pelvic floor, which is more likely to overcome the ability of your urethra to stop urine leaking. If you are particularly overweight, losing weight can, therefore, help reduce incontinence. Research has shown that continence surgery is less successful if you are particularly overweight.

    Chronic cough
    Persistent coughing, like obesity puts greater pressure on the pelvic floor.

    Lax joints
    Some women have problems with their body connective tissue, making it weaker. As a result urethral and pelvic floor supports are not as strong as those women with normal tissue. Incontinence has been reported as a common problem in young female athletes.

    Constipation
    Constipation may lead to straining and an increase in the pressure on the pelvic floor.

    Some drugs such as doxazosin which is used to treat high blood pressure, can make SUI worse. It may be worth asking your family doctor to change your medication to see if it has any effect.