Stress Urinary Incontinence
Stress Urinary Incontinence (SUI) refers to urinary leakage with sudden pressure on the bladder and urethra, such as during coughing, laughing, sneezing, or lifting heavier objects. Mild SUI may not cause much bother and often patients wear a small absorbent pad or liner.
If your SUI is more severe, however, you may also leak with less forceful activities such as standing up, walking, or bending. In these cases, urinary accidents can lead to changing multiple soaked pads daily. Patients with moderate-severe SUI usually seek treatment with a Urologist.
Causes of SUI
The pelvic floor muscles and connective tissue support the bladder and urethra. Damaging, weakening, or stretching of these supportive tissues can cause stress urinary incontinence. Examples of conditions that can cause SUI include pregnancy, childbirth, chronic cough, a history of prior pelvic surgery, obesity, and smoking.
SUI is very common in women as they age. In men, SUI usually occurs following surgery for prostate cancer, and rarely occurs with benign enlarged prostate surgeries such as a transurethral resection of the prostate (TURP). Both men and women can develop SUI following injury to the lower spinal cord, which can cause a weakened urinary sphincter. In this instance, the sphincter loses its ability to hold urine in the bladder leading to bothersome leakage. This is referred to as intrinsic sphincter deficiency.
Stress incontinence should not be confused with Urge Urinary incontinence (UUI). Patients with UUI have sudden urges to urinate and will leak before making it to a bathroom. UUI is a much different condition and has different treatments. Stress Incontinence is usually treated surgically, whereas Urge Incontinence is treated either with medication (anti-cholinergic, beta3-agonist) or Botox injected into the bladder via telescope. Some patients have both SUI and UUI, a condition called Mixed Incontinence, that may need a more tailored plan.
Treatment Options for SUI
Mild SUI is typically the most responsive to the behavioral modifications listed below:
- Weight Loss: decreases stress on the pelvic floor
- Kegel Exercises: squeeze and relax the pelvic floor muscles daily to strengthen muscles supporting the urethra, bladder, and uterus
- Treat Underlying Constipation: maintain soft, regular stools with daily fiber supplementation
- Smoking Cessation
Patients with moderate to severe stress incontinence often seek treatment with a urologist as behavioral modifications are insufficient to prevent leakage. Medications are not effective in this condition; surgical therapy is the next step.
SUI Surgery for Women
Urethral Bulking Agents are injected into the urethra in a minimally invasive procedure using a telescope. The goal is to maintain a watertight closure in the urethra. This procedure is done much less than in the past, as it is not as effective for long-term continence and requires frequent re-treatments.
Mid-urethral Sling is also a minimally invasive procedure in which a sling is surgically placed underneath the urethra to act as a hammock to support the bladder, urethra, and pelvic floor. Slings are made of a synthetic mesh and recovery time is short. Unfortunately, slings carry a risk of mesh erosion into the vaginal lining, which can lead to pelvic pain, irritative bladder symptoms, and pain with sexual intercourse. These complications require immediate surgical removal. Your surgeon avoids the use of synthetic mesh to prevent these significant complications.
Pubovaginal Sling uses the patient’s own fascia (strong tissue that covers muscle) or cadaveric fascia to create a sling to support the bladder. It involves a small incision in the vagina and a slightly larger incision at the bikini-line to harvest the sling fascia. This procedure is very effective in treating SUI and is long-lasting. There is no mesh erosion risk since the tissue is biological not synthetic. A pubovaginal sling is the gold standard for SUI treatment in women.
SUI Surgery for Men
Male Sling is a surgically implanted synthetic strap to support and close the urethra. This is ideal for patients with mild to moderate stress urinary incontinence typically seen after surgical removal of the prostate or radiation to treat cancer. It can also be implanted when there is nerve damage to the urinary sphincter when pelvic or lower spinal nerves have been damaged.
Artificial Urinary Sphincter (AUS) is reserved for moderate to severe SUI in men and is the most effective treatment for total continence. The device has 3 parts: a cuff which wraps around the urethra and inflates, a pump implanted just under the scrotal skin, and a reservoir implanted in the perineum. This procedure can be done with a same-day discharge to home. To urinate, the scrotal pump is squeezed 2 to 3 times to transfer water from the urethral cuff to the reservoir. This opens the urethra and allows the patient to empty their bladder. The cuff then automatically re-inflates with water to allow continence between bathroom breaks. The AUS device can cure or greatly improve continence.