Stress Urinary Incontinence, assessment and treatment options

Introduction

Stress urinary incontinence (SUI) is involuntary loss of urine on physical exertion. Activities provoking stress incontinence include sneezing, coughing or exercise. Stress incontinence can affect women’s quality of life. SUI and urgency urinary incontinence (UUI) may coexist (mixed urinary incontinence). SUI in adult women may be a consequence of defects in urethral support, urethral coaptation, or neurological causes.

Predisposing factors include pregnancy and childbirth, obesity and constipation. SUI is commonly associated with pelvic organ prolapse (POP).

Symptoms include lack of urinary control that results in leakage of variable volumes of urine.

Often the leakage will necessitate the use of pads for protection. Women may restrict physical activity or water intake to maintain low urine volumes and reduce incontinence episodes. Secondary effects of incontinence may be present such as excoriation of the skin or fungal skin infections. Urine odour can be particularly embarrassing.

Assessment

A thorough medical history and detailed pelvic examination are essential to the diagnosis of SUI. A bladder diary can be particularly helpful in obtaining detailed information about fluid type and amount intake, as well as urine volumes, triggers and incontinence episodes.  A positive cough stress test on pelvic examination can be diagnostic:  loss of urine is visually confirmed by having the patient cough and observing leak of urine through the urethra. POP should be also looked for during clinical examination.

A urinalysis is necessary to rule out infection as this can sometimes cause SUI symptoms. If the patient assessment confirms SUI +/- POP and there are no complicating factors such as urgency urinary incontinence or failed prior surgery for SUI, one can then establish a plan of care based on the woman’s preferences and expectations. Urodynamic investigations evaluate the function of the bladder and urethra during the storage and voiding phases of micturition. The test aims to reproduce the patient symptoms, confirm the nature of the problem and provide guidance for the choice of therapy. Ultrasonography of the pelvis and urinary tract may be indicated based on history and clinical examination findings.

Treatment

First line therapy, particularly for mild SUI, consists of pelvic floor exercises in order to strengthen the pelvic floor muscle tone. Additional treatments in persistent cases include biofeedback and electrostimulation. Vaginal support pessaries have also been used to alleviate symptoms.

Definitive therapy for SUI is surgical and usually involves restoring urethral support using a midurethral sling of synthetic mesh. Long-term data demonstrate high efficacy with low complication rates, particularly in experienced hands. Various techniques for sling insertion have been developed and appear to have similar efficacy rates. An additional advantage of the slings is that they can be undertaken concomitantly with procedures for the repair of POP.

Another effective intervention for SUI is the injection of urethral bulking agents. These procedures have gained popularity especially following recent published reports about the safety of synthetic meshes and negative publicity triggered by complicated cases. Bulking agents are injected directly into the urethra under vision and aim to improve  coaptation of the urethral lumen. The loss of effect over time may indicate “top-up” injections. They are particularly suitable for young women of childbearing age and those with mild symptoms. In complex cases such as those of prior failed anti-incontinence sling procedures, urethral bulking, a second sling or a different surgical approach can be considered. However, recurrent procedures have usually lower success rates compared to primary procedures, and therefore it is important to “get it right first time”.

Conclusion

SUI is a common condition that adversely affects women’s quality of life. Unfortunately, many women continue to regard SUI as an inevitable consequence of “getting older”. The availability of minimally invasive procedures and definitive surgical approaches means that all patients with SUI can be successfully treated, or, at the very least, their condition significantly improved.

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