About Stress Urinary Incontinence (SUI)

Weakened pelvic floor muscles cannot support the bladder and urine outlet (urethra) as well as they should. The pressure is too much for the bladder outlet to withstand and so urine leaks out.

Childbirth is a common reason for a weak pelvic floor. The main treatment for stress incontinence is pelvic floor exercises. Surgery to tighten or support the bladder outlet can also help to relieve the leaking urine. Medication may be used in addition to exercises if you do not want, or are not suitable for, surgery.

Signs and Symptoms of Stress Urinary Incontinence (SUI)

SUI’s hallmark is urine leakage triggered by physical stress, but its presentation varies in frequency, severity, and context. Here’s an expanded breakdown:

1. Urine Leakage During Physical Activity

• Description: Small to moderate amounts of urine escape involuntarily when abdominal pressure rises.
• Triggers:
  • Coughing or sneezing (sudden pressure spikes).
  • Laughing (diaphragm movement).
  • Exercising (e.g., running, jumping, lifting weights).
  • Bending over or standing up quickly.
• Pattern: Leakage is immediate and brief, stopping once the activity ends, unlike continuous dribbling.
• Severity: Ranges from a few drops to a noticeable stream, depending on muscle weakness and pressure intensity.
• Context: Often predictable—patients may anticipate it during specific actions.

2. Absence of Urge Sensation

• Description: No sudden or overwhelming need to urinate precedes the leakage, distinguishing SUI from urge incontinence.
• Cause: The issue is mechanical (sphincter failure under stress), not neurological or bladder-driven.
• Significance: Patients typically feel in control of their bladder until the triggering event occurs.
• Contrast: Unlike overactive bladder, there’s no “gotta go now” feeling—just unexpected leakage.

3. Wetness or Dampness

• Description: A sensation of wetness in the underwear or on the skin after a leak, often noticed post-activity.
• Frequency: May occur multiple times daily (e.g., with every cough) or only during intense exertion, depending on severity.
• Impact: Can lead to frequent pad or clothing changes, especially in moderate to severe cases.
• Observation: Patients may not feel the leak as it happens but notice dampness afterward.

4. Embarrassment or Social Withdrawal (Secondary Symptom)

• Description: Emotional distress or avoidance of activities due to fear of leakage.
• Cause: Visible wet spots, odor, or unpredictability can erode confidence.
• Examples: Skipping exercise classes, avoiding social laughter, or carrying spare clothes/pads.
• Significance: While not a physical sign, it’s a common consequence affecting quality of life.

5. Pelvic Pressure or Discomfort (Mild or Occasional)

• Description: A subtle heaviness or bulging sensation in the pelvic area, especially in women with pelvic organ prolapse alongside SUI.
• Cause: Weakened pelvic support (e.g., from childbirth) may contribute to both prolapse and incontinence, amplifying symptoms.
• Frequency: Not universal—more common in severe cases or with coexisting conditions.
• Note: Distinct from bladder pain or urgency; it’s a structural rather than inflammatory symptom.

6. No Leakage at Rest

• Description: Urine stays contained when lying down, sitting, or standing still, with leakage only during stress events.
• Cause: The sphincter holds under baseline pressure but fails when abdominal force exceeds its strength.
• Significance: Helps differentiate SUI from overflow incontinence (constant dribbling) or mixed incontinence (stress + urge).
• Observation: Patients often report normal bladder control outside of triggering moments.

7. Increased Frequency with Risk Factors

• Description: Symptoms worsen with conditions like chronic cough (e.g., from smoking or asthma), obesity, or post-surgical changes.
• Cause: Extra pressure from coughing or weight strains the pelvic floor further; prostate surgery (in men) damages sphincter nerves or muscles.
• Examples: A smoker with a persistent cough may leak daily, or a woman post-delivery may notice it during exercise.
• Progression: Symptoms may escalate over time without intervention.

In Men vs. Women

• Women: More common due to pregnancy, childbirth, and menopause weakening pelvic structures. Leakage often ties to daily activities (e.g., lifting kids).
• Men: Rarer, typically post-prostatectomy (e.g., after prostate cancer surgery), with leakage during exertion or positional changes. Symptoms may be less frequent but equally disruptive.

Stress Urinary Incontinence (SUI) Causes :

• Childbirth. Most cases of stress incontinence are due to weakened pelvic floor muscles. Pelvic floor muscles are often weakened by childbirth. The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and urethra, and the back passage (rectum). Stress incontinence is common in women who have had children, particularly if they have had several vaginal deliveries.
• Age. It is also more common with increasing age, as the muscles become weaker as a part of aging, particularly after the menopause.
• Obesity. Stress incontinence is also more common in women who are obese.
• Surgeries. Stress incontinence can occur in men who have had some treatments for prostate cancer. This includes surgical removal of the prostate (prostatectomy) and radiotherapy.

Risk Factor of Stress Urinary Incontinence (SUI)

1. Gender (Female Predominance)

• Why: Women are at higher risk due to anatomical and reproductive factors.
• Details: The female urethra is shorter (about 3-4 cm vs. 20 cm in men), offering less resistance to pressure. Pregnancy, childbirth, and menopause further weaken pelvic support.
• Prevalence: Up to 35-50% of women experience SUI at some point, compared to 3-11% of men, mostly post-prostate surgery.
• Context: Menopause drops estrogen, thinning urethral tissues and reducing closure strength.

2. Pregnancy and Childbirth

• Why: These strain and stretch pelvic floor muscles and nerves.
• Details:
  • Pregnancy: The growing uterus presses on the bladder, while hormonal changes (e.g., relaxing) loosen ligaments.
  • Vaginal Delivery: Stretching or tearing of pelvic muscles, nerve damage (e.g., pudendal nerve), or forceps use weakened support. Multiple births or large babies (macrosomia) amplify risk.
• Impact: Up to 30-40% of women report SUI post-delivery; risk rises with each vaginal birth.
• Note: Cesarean delivery lowers but doesn’t eliminate risk, as pregnancy alone stresses the pelvis.

3. Aging

• Why: Muscle and tissue strength decline naturally over time.
• Details: After age 40-50, pelvic floor muscles lose tone, and collagen in connective tissues weakens, reducing urethral support. In women, menopause accelerates this via estrogen loss; in men, age-related muscle atrophy plays a role.
• Prevalence: SUI incidence climbs with age—e.g., 10-15% in women under 40 vs. 30-40% over 60.
• Context: Aging also slows nerve signals, subtly impairing sphincter control.

4. Obesity

• Why: Excess weight chronically stresses the pelvic floor.
• Details: Abdominal fat increases pressure on the bladder and urethra, overtaxing weakened muscles. A BMI over 30 doubles SUI risk; each 5-unit BMI increase raises odds by 20-70%.
• Impact: Common in both genders, but women with obesity report higher leakage rates during activity.
• Reversibility: Weight loss (e.g., 5-10% reduction) can significantly reduce symptoms.

5. Prostate Surgery (Men)

• Why: Surgical damage to the urethral sphincter or nerves causes SUI in men.
• Details: Radical prostatectomy (for prostate cancer) or transurethral resection (for BPH) can weaken or remove the external sphincter, disrupting closure. Up to 50-90% of men experience temporary SUI post-prostatectomy; 5-20% have persistent issues.
• Context: Risk is higher with radical vs. partial procedures and varies with surgical skill.
• Contrast: Rare in men without such surgery.

6. Chronic Cough or Respiratory Conditions

• Why: Repeated pressure from coughing strains pelvic support.
• Details: Conditions like chronic obstructive pulmonary disease (COPD), asthma, or smoking-related coughs create frequent abdominal force, weakening the sphincter over time. Smokers face dual risk from cough and tissue damage (nicotine reduces collagen).
• Impact: Leakage often ties directly to coughing episodes, worsening with condition severity.
• Prevalence: Higher in older adults with long-term respiratory issues.

7. High-Impact Physical Activity

• Why: Repetitive stress from intense exercise can overstretch pelvic muscles.
• Details: Athletes (e.g., runners, gymnasts) or those doing heavy lifting face increased risk, especially women. Studies show 20-40% of female athletes report SUI, linked to repetitive pelvic floor strain.
• Context: More common in younger, active women without childbirth history, suggesting overuse as a factor.
• Note: Proper technique (e.g., engaging core) may mitigate risk.

8. Family History/Genetics

• Why: Inherited traits affect pelvic tissue strength.
• Details: A family history of SUI or pelvic organ prolapse suggests genetic predisposition to weaker connective tissue (e.g., collagen defects). Twin studies show 30-50% heritability.
• Impact: Risk rises if a mother or sister had SUI, especially post-childbirth or with aging.
• Context: Combines with lifestyle factors for cumulative effect.

9. Menopause

• Why: Estrogen loss weakens urethral and pelvic tissues.
• Details: Post-menopause, reduced estrogen thins the urethral lining, shrinks muscle mass, and lowers closure pressure. Up to 40% of postmenopausal women report SUI.
• Context: Often compounds childbirth or aging effects; hormone replacement may help some but isn’t a cure-all.
• Significance: A female-specific accelerator of risk.

10. Neurological or Musculoskeletal Conditions (Less Common)

• Why: Nerve or muscle dysfunction impairs pelvic control.
• Details: Conditions like multiple sclerosis, spinal cord injury, or severe arthritis limit muscle coordination or strength, indirectly raising SUI risk. Rare compared to mechanical causes.
• Impact: May overlap with other incontinence types (e.g., urge), complicating diagnosis.
• Context: More relevant in complex medical histories.

Diagnosis of Stress Urinary Incontinence (SUI)

• History of Leakage: Leakage occurs during physical stress (e.g., coughing, sneezing).
• Timing: No leakage with urgency or at rest, distinguishing from urge incontinence.
• Pelvic Exam (Women): Weak pelvic floor muscles or urethral hypermobility noted.
• Rectal Exam (Men): Assesses sphincter tone, often post-prostate surgery.
• Cough Stress Test: Urine leaks when coughing with a full bladder.
• Urinalysis: Rules out infection or blood causing similar symptoms.
• Bladder Diary: Tracks leakage tied to activity, not random times.
• Post-Void Residual: Normal (<50 mL) confirms no overflow issue.
• Urodynamics (if complex): Confirms low urethral pressure during stress.
• Pad Test: Quantifies leakage (e.g., >1 g/hour during activity).
• Risk Factor Check: Links to childbirth, menopause, or prostatectomy.

Treatment of Stress Urinary Incontinence (SUI)

First-line treatment for stress incontinence involves pelvic floor exercises to strengthen your pelvic floor muscles. About 6 in 10 cases of stress incontinence can be cured or much improved with this treatment. If you are overweight and incontinent then you should first try to lose weight in conjunction with any other treatments. Medication may be used in addition to exercises if you do not want, or are not suitable for, surgery.

MASSH Hospital also provides specialized & advanced solutions for weight loss.

Surgery management:

TOT (Trans-Obturator Tape): It is a minimally invasive surgery to treat SUI, where urine leaks during activities like coughing or exercising. A synthetic mesh tape is placed under the urethra via the obturator foramen, supporting it like a hammock to prevent leakage. Done in 30–45 minutes under anesthesia, it boasts an 85–90% success rate, quick recovery (1–2 weeks), and lower complication risks (e.g., bladder injury) than older slings. Ideal for moderate to severe SUI, it’s a durable fix with minimal downtime.

TVT (Tension-Free Vaginal Tape): TVT is a minimally invasive surgery to treat SUI, where urine leaks during physical stress like coughing or lifting. A synthetic mesh tape is placed under the urethra through small vaginal and abdominal incisions, passing behind the pubic bone (retropubic route) to support the urethra without tension. Performed in 30–45 minutes under anesthesia, it offers a 85–90% success rate, with recovery in 1–2 weeks. While effective, it carries a slightly higher risk of bladder injury (5–10%) compared to TOT.