Many women remain silent and reticent to explore options for managing stress incontinence. The most common form of urinary incontinence is stress incontinence and it occurs during activities that increase abdominal pressure (e.g., while coughing, sneezing, laughing, lifting heavy objects or during physical activity). During these activities, increased abdominal pressure can bear down on the bladder, forcing the urethra to open and resulting in the loss of urine.
Stress incontinence most often results from weakened pelvic floor muscles and connective tissue. These structures support the bladder. Their effectiveness can be influenced by pregnancy, childbirth and menopause.
Pregnancy – during pregnancy, hormonal changes and the extra weight and pressure of the baby contribute to weakening. The pelvic floor muscles may also be weakened during childbirth, particularly in a prolonged second stage of labour, if the baby is bigger than 4 kg in weight or if instruments are used in the delivery. It is common for women to experience some degree of incontinence during pregnancy and following childbirth. Women who don’t experience incontinence during pregnancy may also begin to leak urine following birth – in fact, up to 30% of women who experience no continence issues during pregnancy, experience some form of bladder leakage following birth.
Menopause – at menopause, the reduction in oestrogen levels can contribute to a loss of tone in the urethra, affecting its closing pressure. Reduced oestrogen levels also cause the pelvic floor muscles to become less elastic and therefore may aggravate existing muscle weakness.
Other – being overweight or obese can lead to stress incontinence as the pelvic floor muscles are forced to carry a heavier load. Pelvic floor weakness can also be caused by the straining often associated with constipation or chronic coughing. Smoking is therefore associated with stress incontinence as smokers often suffer from chronic coughing. It has also been found that some women have a genetic predisposition to pelvic floor weakness. Also, it is important to be aware that some exercise programs place more strain on the pelvic floor than others; while it is important to exercise regularly, it is also important to know which exercise options are safe, and to seek professional guidance if you are at risk of pelvic floor problems.
Pelvic floor exercises – also referred to as Kegel exercises, pelvic floor exercises are designed to strengthen the pelvic floor muscles through actively tightening and lifting them at intervals. Strong, well-activated pelvic floor muscles help support the bladder, uterus and bowel and allow the urethral sphincter to function properly. The exercises are designed to work these muscles and therefore help with control of the bladder and bowel.
You can perform pelvic floor exercises while you are sitting, standing or lying down. You can do them while waiting in a queue, or sitting with good posture at traffic lights or at the office desk, without anyone noticing. The number of exercises required depends on your existing pelvic floor muscle strength. It may take 2-3 months to notice a significant improvement. As with any exercise program, women should start gradually by slowly building up the number of contractions and women should perform the exercises regularly. It is also important to activate your pelvic floor muscles as part of good sitting and standing postures and before/during activities that place downward pressure on your pelvic floor (i.e., sneezing, coughing or lifting).
To learn how to perform the exercises properly and determine an appropriate individual exercise program it is recommended that you see a physiotherapist with a special interest in pelvic floor dysfunction, who can make sure you are using the correct muscles in the right way. Regular supervision from a physiotherapist will increase the effectiveness of your pelvic floor exercise routine.
Vaginal cones – these can be used to help you identify your pelvic floor muscles. The cones come in different weights and are placed inside the vagina while you are standing up. You then contract your pelvic floor muscles to hold the cone in place and prevent it from slipping. As your pelvic floor muscles become stronger you can increase the weight of the cones you are using.
Biofeedback – biofeedback uses a sensor to measure pelvic floor muscle contractions in order to provide immediate ‘feedback’ to a woman on whether she is performing the exercises correctly. There are two types of sensor. One type is a skin patch that can be worn externally; the other is an internal sensor that is placed in the vagina.
Electrical stimulation – if a woman’s pelvic floor muscles are very weak or the nerve supply to the muscles is damaged, electrical stimulation may be an option. It consists of temporarily placing electrodes in the vagina and/or rectum. Small pulses of electricity generate muscle contractions and can help women identify how to do the contractions themselves.
Electromagnetic stimulation – during this therapy women sit, fully clothed, in a specially designed chair that produces pulsed magnetic fields. These fields cause the pelvic floor muscles to contract and relax. The medical community’s views on this treatment option are currently divided. Further studies are required to assess its long-term effectiveness.
Weight loss – achieving sensible weight loss through a combination of dietary changes and regular exercise can lead to an improvement in urinary incontinence symptoms. Weight loss can reduce the amount of pressure placed on the pelvic floor.
Pessaries – these may be an option for women who have incontinence as a result of genital prolapse, but for whom surgery or other treatments are unsuitable (e.g., elderly women). Pessaries are placed in the vagina, where they help re-position the bladder and urethra, limiting the leakage of urine. Pessaries must be fitted by a medical professional. Pessaries do not deal with the underlying cause of the incontinence and they can cause irritation and increase the risk of urinary infections.
Oestrogen therapy – there is evidence to suggest that topical oestrogen creams may improve continence in women. While oestrogen creams may be helpful, results from a recent large trial found that oral hormone replacement therapy (HRT) actually increases a woman’s risk of urinary incontinence and may worsen symptoms in women with incontinence. Oral HRT should not be used to treat urinary incontinence.
Urethral injections – substances such as collagen, fat or synthetic materials can be injected into the tissues around the urethra to ‘bulk up’ the area and tighten the seal of the urethra. Urethral injections may need to be topped up and can be costly. They do, however, provide an alternative for women who are unable or do not wish to have surgical treatment.
SURGICAL TREATMENT OPTIONS
Generally, surgery for stress incontinence aims to reposition the bladder and urethra to their normal positions and/or provide the bladder with support. There are two main surgical approaches: colposuspension and sling procedure.
Colposuspension – this procedure involves the bladder neck being lifted back to its proper position. The front wall of the vagina (where the urethra is located) is lifted and stitched to strong ligaments near the pubic bone. The most popular type of colposuspension procedure is Burch colposuspension, which can be performed both abdominally and laparoscopically (key-hole surgery).
Sling procedure – in this procedure, a piece of fascia (strong tissue that covers the body’s muscles) or a synthetic material such as mesh tape, is placed under the urethra like a hammock to support it. Some sling procedures are performed while you are under a general anaesthetic, while others can be done using a regional anaesthetic. The procedure generally requires small incisions in the abdomen and/or vagina.
Surgery should only be considered after you have trialled conservative treatments and undergone a urodynamic assessment to ensure the diagnosis is correct and your condition is favourable to surgical correction. Success rates and risks vary for different procedures and so you should discuss this with your doctor prior to surgery. Surgery may not result in a complete resolution of incontinence symptoms. Surgery is generally not performed unless a woman is not planning any further pregnancies, as pregnancy will impact the ongoing results.