This is involuntary leakage of urine during situations of increased pressure in the abdomen caused by coughing, sneezing, laughing, effort and excretion. This is due to the weakness of the muscles that support the bladder in position. These muscles are located in the lower part of the pelvis and are called pelvic floor muscles. These muscles are damaged or weakened by pregnancy and childbirth.
However, the stress incontinence usually does not manifest until well into the 40’s even though the weakness would have occurred much earlier in life due to pregnancy and childbirth. This is because of the progressive weakening of the body’s supporting tissue called collagen, which tends to occur during the late 40’s for a woman when she goes into menopause.
Treatment for Stress Incontinence
The treatment of stress incontinence is mainly by increasing the resistance at the urethra or support the urethra by different means. Conservatively, it is done by regular pelvic floor exercises to strengthen the pelvic floor muscle thereby increasing the resistance at the level of the urethra and reduce or prevent the leakages associated with coughing and straining.
How can I perform pelvic floor exercises?
To do the pelvic floor muscle exercise, the first thing to do is to identify these muscles. These are the muscles that you would be contracting to stop breaking wind or stop urinating. You will need to contract those muscles in sets of 10 – 20 many times a day achieving a total of 60 – 80 contractions per day. Once you have mastered the ability to contract these muscles you could contract and sustain for a few seconds and release which is called ‘slow contractions’ and to contract and release quickly called ‘fast contractions’. If you could achieve this level of contractions and maintain 60-80 contractions per day you are likely to see improvement in your stress incontinence. After mastering the ability to contract these muscles, at your voluntary control you may contract your pelvic floor muscles before the situations of vulnerability like coughing, laughing and straining. What you would do in the situation (for example just before a cough) is to pull your pelvic floor muscles up by contracting them and cough (or sneeze or laugh) which could avoid the situations of leakage. This is called KNACK manoeuvre.
What treatment will I receive if I am unable to get enough improve with pelvic floor exercises (rehabilitation)?
If you continue to have bothersome leakage after sufficient pelvic floor exercises your urologist would give you an option for surgical treatment for stress urinary incontinence. He or she is likely to carry out the Urodynamics test. The surgical treatment options are:
Insertion of tension free vaginal tapes or mid urethral slings (these are the slings which are inserted to support the mid part of the urethra and increase the resistance at the level of the urethra and cure or prevent stress leaks) or a procedure called colpo-suspension. The slings used can be synthetic slings or natural slings (made from tissue in your body – tissue taken from the side of the thigh or sheath covering the long muscle in the abdomen). However, now days are artificial slings made from polytetrafluoroethylene (PTFE) is used.
These tapes can be inserted in two ways:
- Retro pubic (tapes are inserted from behind the urethra and they loop around the urethra and come behind the pubis).
- Transobturator tape are inserted from the inner part of the upper most thigh and stretch across to the other side just behind the urethra parallel to the front wall of the vagina.
In general the success rates of both types of tapes are relatively the same. The retro-pubic tapes have slightly higher success rates those they have slightly increased complications of bladder injury during the insertion of the tapes and also slightly higher rate of having to use a catheter to empty the bladder following the tape operation. Transobturator tapes have a slightly reduced risk of causing obstruction of the urethra requiring subluxation.
In patients suffering with mixed urinary incontinence, the predominant condition will be treated first. Usually one would start with conservative treatment which would include bladder retaining, lifestyle changes, pelvic floor exercises and also treatment with medication which can all be done at the same time. When we proceed to the invasive treatment the most bothersome problem will be treated first.