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Stress Incontinence

Definition :
Incontinence is the unintentional loss of urine. Stress incontinence is prompted by a physical movement or activity, such as coughing, sneezing or heavy lifting, that puts pressure — stress — on your bladder. Stress incontinence is not related to psychological stress.

Stress incontinence is much more common in women than in men.

If you have stress incontinence, you may feel embarrassed, isolate yourself or limit your work and social life. A combination of treatments may enable you to manage stress incontinence and improve your overall well-being.

Causes :
Stress incontinence occurs because of dysfunction in the mechanisms that normally control release of urine from your bladder.

Normal bladder function
Your kidneys produce urine, which travels down a pair of long tubes from your kidneys to your bladder. Urine drains from your bladder through an opening at the bottom (neck) and flows out a short tube called the urethra (u-RE-thruh). In women, the urethral opening is

located just above the vagina. In men, the urethral opening is at the tip of the penis.

The muscles of the pelvic floor support your bladder and stabilize the bladder neck and urethra. Muscles of the bladder neck and the urethra (urinary sphincter) act as a kind of valve, controlling the release of urine.

Your bladder expands as it fills with urine. The contracted sphincter prevents urine from draining out of the bladder. When you urinate (void), nerve signals coordinate the relaxation of the pelvic floor muscles and sphincter and contraction of the bladder muscles.

Poor urinary control
Stress incontinence occurs because of poor function in pelvic floor muscles, the sphincter or both. When you sneeze, or exert some other force on the abdomen, the pressure on your bladder increases. If the bladder neck and urethra aren't sufficiently supported or the sphincter muscles aren't strong enough, the sphincter can't hold back the urine in the bladder. Reasons for sphincter dysfunction may include the following :

  • Childbirth. In women, poor function of pelvic floor muscles or the sphincter may occur because of tissue or nerve damage incurred during delivery of a child. Stress incontinence from this damage may begin soon after delivery or years later.
  • Prostate surgery. In men, the most common factor leading to stress incontinence is the surgical removal of the prostate gland (prostatectomy) to treat prostate cancer. Because the prostate gland encircles the urethra, a prostatectomy results in less urethral support.

Contributing factors
Other factors that may exacerbate stress incontinence include :

  • Urinary tract infection
  • Illnesses that cause chronic coughing or sneezing
  • Smoking, which can cause frequent coughing
  • Diabetes, which can cause excess urine production and nerve damage
  • Excess consumption of caffeine or alcohol
  • Medications that cause a rapid increase in urine production
  • Sports, such as tennis or running

Risk Factor :
Factors that increase the risk of developing stress incontinence include the following :

  • Age. Although stress incontinence isn't a normal part of aging, physical changes associated with aging, such as the weakening of muscles, may make you more susceptible to stress incontinence.
  • Type of delivery. Forceps delivery of a baby may be associated with a greater risk of stress incontinence than is normal vaginal delivery. Multiple deliveries also may be associated with a higher risk.
  • Obesity. People who are obese have a much higher risk of stress incontinence. Excess weight increases pressure on the abdominal organs. Subsequently, the "resting" pressure on the bladder may be significant even without the additional pressure from a cough or other force.

When to seek medical advice :
Talk to your doctor if the symptoms of stress incontinence interfere with your activities of daily living, such as your work, interpersonal relationships, social life and general well-being.

Symptoms :
If you have stress incontinence, you may experience urine leakage when you :
  • Cough
  • Sneeze
  • Laugh
  • Stand up
  • Lift something heavy
  • Exercise

You may not experience incontinence every time you do one of these things, but these pressure-increasing activities can make you more vulnerable to unintentional urine loss, particularly when your bladder is full.

Diagnosis :
Common clinical assessments
Your doctor may use a questionnaire to make a preliminary assessment of your symptoms. You may also be asked to keep a voiding diary for a few days. You'll record when, how much and what kind of fluids you consume; when you urinate; and when you experience incontinence. Your diary may reveal patterns that help your doctor understand symptoms and identify contributing factors.

In a basic diagnostic workup, your doctor will look for clues that may also indicate contributing factors. The exam will include :

  • A medical history
  • A complete physical examination with particular focus on your abdomen and genitals
  • A urine sample to test for infection, traces of blood or other abnormalities
  • A neurological exam to identify sensory problems
  • A urinary stress test, in which the doctor observes urine loss when you cough or bear down on your abdomen

Specialized tests
Your doctor may order urodynamic tests, which are used to assess the function of your bladder. These tests usually require a referral to a specialist in urinary disorders (urologist) or urinary disorders in women (urogynecologist). Common tests include :

  • Measurements of postvoid residual urine. When you urinate or experience urinary incontinence, your bladder may not empty completely. The remaining urine volume (postvoid residual urine) may exacerbate symptoms of overactive bladder. To measure residual urine after you have voided, a thin tube (catheter) is passed through the urethra and into your bladder. The catheter drains the remaining urine, which can then be measured. Alternatively, a specialist may use an ultrasound scan, which translates sound waves into an image of your bladder and its contents.
  • Cystometry. Cystometry measures pressure in your bladder and in the surrounding region during bladder filling. A catheter is used to fill your bladder slowly with warm water. Another catheter with a pressure-measuring sensor device will be placed in your rectum. This procedure, when combined with a voiding study, can identify problems with the urethra exerting too little pressure against bladder pressure.
  • Video urodynamics. These procedures use either X-ray or ultrasound waves to create pictures of your bladder as it's filling and emptying. Your bladder is filled with the use of a catheter, and you urinate to empty your bladder. The fluid may contain a special dye that can be detected by X-ray technology. This test is often combined with cystometry.
  • Cystoscopy. A cystoscope, a thin tube with a tiny lens, enables your doctor to see the inside of your urethra and bladder. With the aid of this device, your doctor can check for abnormalities in your lower urinary tract.

Your doctor will review the results of these tests with you and suggest a treatment strategy.

Complications :
If you experience stress incontinence, you may feel embarrassed and distressed by the condition. It often disrupts work, social activities, interpersonal relationships and sexual relations.

Some people may have a disorder called mixed incontinence. This is usually the presence of both stress incontinence and urge incontinence. Urge incontinence is the loss of urine resulting from an involuntary contraction of bladder muscles (overactive bladder).

Treatment:
Your doctor is likely to recommend a combination of treatment strategies to end or lessen the number of incontinence episodes. If underlying causal or contributing factors, such as a urinary tract infection, have been identified, you'll also receive treatments to address those conditions.

Behavioral interventions
Behavioral interventions may help you eliminate or lessen episodes of stress incontinence. The stress incontinence treatments your doctor will recommend may cover the following areas:

  • Fluid consumption. Your doctor may recommend the amount and timing of fluid consumption during the day. You should also avoid caffeinated and alcoholic beverages.
  • Healthy lifestyle changes. Quitting smoking or losing weight may lessen your vulnerability to stress incontinence and improve symptoms if you do have stress incontinence.
  • Scheduled toilet trips. Your doctor may recommend a schedule for toileting. More frequent voiding of the bladder may reduce the number or severity of stress incontinence episodes.
  • Pelvic floor muscle exercises. Exercises called Kegels strengthen your pelvic floor muscles and urinary sphincter. Your doctor or a physical therapist can help you learn how to do these exercises correctly.
  • Absorbent pads. You can wear absorbent pads or undergarments to protect your clothing and avoid embarrassing incidents if you do experience incontinence.

Devices
Certain devices designed for women may help control stress incontinence. These devices include:

  • Vaginal weighted cones. These tampon-shaped devices of increasing weight are intended to improve the strength of pelvic floor muscles. By holding a weight in place in your vagina, you should be correctly contracting the pelvic floor muscles.
  • Bladder neck support. This device inserted into the vagina lifts the bladder, providing support of the bladder neck. It's generally used temporarily to prevent incontinence during a specific activity, such as playing sports.
  • Urethral plug. This small tampon-like disposable device inserted into the urethra acts as a plug to prevent leakage. It's usually used to prevent incontinence during a specific activity.

Surgery
Surgical interventions to treat stress incontinence are generally designed to improve closure of the sphincter or support the bladder neck. Surgical interventions include:

  • Injectable bulking agents. Collagen, synthetic sugars or gels may be injected into tissues around the upper portion of the urethra. These materials increase pressure on the urethra, improving the closing ability of the sphincter. Because this intervention is relatively noninvasive and inexpensive, it may be an appropriate treatment alternative to try before other surgical options.
  • Open retropubic colposuspension. This procedure is often used to treat women with stress incontinence. Sutures attached either to ligaments or to bone lift and support tissues near the bladder neck and upper portion of the urethra.
  • Sling procedure. In this procedure most often performed for women, the surgeon uses the person's own tissue or a synthetic material to create a "sling" that supports the urethra.
  • Inflatable artificial sphincter. This surgically implanted device is most often used to treat men. A cuff, which fits around the upper portion of the urethra, replaces the function of the sphincter. Tubes connect the cuff to a pressure-regulating balloon in the pelvic region and a manually operated pump in the scrotum. If the device is implanted in a woman, the pump is in the labia.

Prevention:
Stress incontinence isn't a preventable disorder. Healthy lifestyle choices that may reduce your risk or lessen complications of the disorder include a regular exercise routine, weight management, and limited consumption of caffeine and alcohol.

 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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