Patient information from BMJ

Stress incontinence in women

Last published:Aug 30, 2022

If you often leak urine when you sneeze, laugh, cough, or exercise, you probably have a condition called stress incontinence. There are treatments that work well, including simple exercises.

You can use our information to talk to your doctor and decide which treatments are best for you.

What is it?

Stress incontinence usually happens because the muscles that help control the flow of urine from your bladder have become weak.

If they're weak, these muscles can't cope with any extra pressure on them, say from a sneeze. So if you do sneeze, your bladder neck opens for a second. This lets a bit of urine leak out.

The muscles usually affected are your:

• pelvic floor muscles. These muscles support your bladder and help it hold in urine

• urethral sphincter. This ring of muscles controls the release of urine from your bladder and into your urethra (the tube that carries urine out of your body). It works like a valve. When it opens, urine flows out of your bladder. When it closes, it helps to hold urine in your bladder.

Many women get stress incontinence after they've had a baby. You're also more likely to get stress incontinence if you:

• are older

• have been through the menopause

• get constipation often

• consume caffeine

• do a strenuous activity such as weight lifting, or

• are overweight.

What are the symptoms?

If you have stress incontinence, you leak urine when there's extra pressure on your bladder and the muscles around it. This often happens when you cough, sneeze, laugh, exercise, or lift things.

Usually only a little urine leaks, and it happens very quickly. If you have these symptoms and they bother you, you should see your doctor.

It's usually clear from your symptoms whether you have stress incontinence. But your doctor will ask you questions and may do some tests. Sometimes your symptoms can be caused or made worse by another condition, such as a urinary tract infection.

There are different types of incontinence and your doctor will also want to confirm which type you have.

For example, urge incontinence is when you have a sudden and strong urge to pass urine. The urine comes out in a rush that you can't control. It is usually treated differently to stress incontinence, although sometimes people have both stress and urge incontinence (called mixed incontinence).

What treatments work?

Doctors usually recommend that women first try simple treatments, such as changes to their lifestyle and pelvic floor exercises, before thinking about medicines or surgery.

Lifestyle changes

Certain aspects of your lifestyle may be making your stress incontinence worse. These include consuming caffeine, drinking lots of liquids, and doing types of exercise that put extra strain on your pelvic floor muscles (such as lifting weights).

Reducing or stopping these things may help improve your symptoms. Stopping smoking and drinking less alcohol may also help.

If you have frequent constipation, getting treatment for this may improve your stress incontinence as well. And if you are overweight, losing weight can also help.

Pelvic floor exercises

Pelvic floor exercises strengthen the muscles in your pelvis that help control the flow of urine from your bladder. The exercises involve repeatedly tightening (contracting) and releasing these muscles several times each day. You may also hear these exercises called Kegel exercises.

One way to identify your pelvic floor muscles is to lie down and put your finger in your vagina. Then squeeze your muscles as if you're trying to stop urine coming out. If you feel tightness on your finger, then you've found the right muscles.

You can do these exercises anywhere and at any time. For example, you can do them while watching television. But you need to concentrate, especially at first.

Your doctor, nurse, or a physiotherapist can provide additional advice on how to do these exercises. You can also see our leaflet Stress incontinence: how to do pelvic floor exercises.

If you’re finding it difficult to do pelvic floor exercises, your doctor might suggest trying biofeedback or electrical stimulation.

• Biofeedback can help you learn where your pelvic floor muscles are and how to do pelvic floor exercises correctly. A nurse or physiotherapist puts a monitor in your vagina or rectum. This doesn't hurt.

  You then attempt to tighten your pelvic floor muscles. You know that you're doing the pelvic floor exercises correctly when a sound goes off or an image appears on a screen.

• Electrical stimulation can be used instead of pelvic floor exercises. A nurse or physiotherapist puts a probe in your vagina or rectum, and passes an electric current through the probe and into your pelvic floor muscles.

  This makes the muscles tighten. You shouldn't feel any pain. If you're comfortable using the machine yourself, you can do this at home.

Vaginal devices

These are devices that are put in your vagina to help support the neck of your bladder to stop the leakage of urine. They are made of plastic or other materials, and are fitted by your doctor or nurse. They are sometimes called vaginal pessaries.

Medicines

If the above lifestyle changes and treatments haven't helped, your doctor may recommend taking medicines that can help strengthen the muscles controlling the release of urine from your bladder.

• Usually the first medicine people try is pseudoephedrine. This medicine is often used to treat a stuffy nose, but it can also help with stress incontinence.

• Some medicines that are usually used to treat depression can also be effective for stress incontinence.

If you have gone through the menopause, your doctor might also recommend using a cream, ring, or vaginal tablets that contain the hormone oestrogen. You put all these treatments in your vagina.

After the menopause, your body makes less oestrogen than before. Oestrogen helps to keep your muscles healthy, including your pelvic floor muscles and the sphincter muscles that control the flow of urine from your bladder.

These treatments may help improve stress incontinence by replacing some of the oestrogen that you have lost.

All these medicines can sometimes cause side effects. Your doctor will discuss these with you before you start treatment.

Surgery

If other treatments haven’t helped, or if your stress incontinence is severe, your doctor may recommend having surgery. There are several types of surgery. You and your doctor can talk about what type is best for you. Most operations fall into two general categories:

• Surgery to support the bladder neck. There are many different approaches for this type of surgery. Some of the most common involve putting a sling in place to support the bladder neck. This should make it less likely that you will leak urine when your bladder is put under stress.

• Surgery to help the urethral sphincter stay closed. This surgery usually involves injecting a substance - called a bulking agent - in the tissue around your urethra and bladder neck.

  Examples of bulking agents include special beads and gels. The bulking agent presses on your urethra to help it stay closed when you're not passing urine.

A newer treatment that can help some women with an over-active bladder is called neuromodulation. This involves implanting a small battery-powered device in one of your buttocks.

This device helps control the signals from the nerves near your bladder to your brain, so that you have more control over when you need to urinate.

What will happen to me?

Not all women with stress incontinence find it a problem. If you leak a little urine only occasionally you may not be bothered by it.

But if stress incontinence starts to interfere with your daily life and what you can do, you may lose confidence, and become less social and active. Treatment can help you get your confidence back so that you can lead a full and active life.