Stress Urinary Incontinence

Urinary incontinence affects at least 25 million Americans (per the National Association for Continence).  In the United States alone, the costs to treat urinary incontinence is valued at over 1.2 billion in 2019. Urinary incontinence has been found to reduce social and physical activities and is associated with poor self-rated health, impaired emotional and psychological well-being, impaired sexual relationships, decreased quality of life, and depressive symptoms.

There are several defined types of urinary incontinence, which include urge incontinence, stress incontinence, mixed incontinence (combination of urge and stress) and overflow incontinence. There is a lot to unpack when it comes to urinary incontinence, so here we will discuss stress urinary incontinence (SUI).

Stress urinary incontinence is defined as the involuntary loss of urine with physical exertion such as with coughing, laughing, sneezing or exertion such as exercise. It is the most common form of urinary incontinence. More technically speaking, it is when the pressure within the bladder exceeds the pressure able to maintain closure of the urethra without contraction of the bladder muscle. Or in other words, without actively trying to void, the urethra is unable to maintain closure of its sphincter when pressure increases (such as with coughing, laughing or sneezing). SUI may also be due to increased mobility of the bladder neck. Stress urinary incontinence is not accompanied by a sudden urge to urinate, many people are unaware incontinence is occurring until after the event has already happened – or they are unable to stop leakage from happening.

The continence mechanism is embedded within the pelvic floor structure itself. The pelvic floor consists of muscles arranged in a dome like sheet that acts like a sling to support the bladder, uterus, and rectum. These muscles converge and attach into the perineal body. The pelvic floor also plays an important role in the function of core muscle stabilization. Collectively, your core stability muscles include the abdominals, quadratus lumborum, multifidus, diaphragm, and pelvic floor. The pelvic floor is the floor of the core.

Let’s review the cycle of urinary continence before we explore how incontinence may occur. As the bladder fills, the bladder remains relaxed and the pelvic floor muscles contract to help maintain continence. At around 150-200mL of urine, you feel your first sensation to void (in a typical bladder without symptoms). Once you feel the need to void, and go to do so, your bladder muscle (detrusor) contracts, you release the urethral sphincter, and the pelvic floor muscles relax.

 Specifically, there are two types of stress incontinence: urethral hypermobility and intrinsic sphincteric deficiency (ISD). In the case of urethral hypermobility, the urethra shifts positions due to an increase in abdominal pressure (coughing, sneezing, laughing etc). ISD refers to the inability to effectively seal off the sphincter, the ring of muscles whose main job is to remain tightened, keeping urine in the bladder. While there is no specific test for ISD, it is now generally believed that many women with SUI have at least some degree of ISD.

 So what exactly causes SUI? Pregnancy and childbirth are typically at the top of the list for causes of stress incontinence, but there are other health factors that may put you at risk, too. You may experience incontinence even if you have not had children. Risk factors include:

1.    Loss of pelvic muscle tone. This can often occur with aging or childbirth, although people of all ages can develop SUI.

2.    Hysterectomy (or any other surgery that affects your pelvic floor)

3.    Nerve and muscle damage from childbirth or surgical trauma

4.    Obesity

5.    Menopause

6.    Chronic coughing due to smoking and lung disease

7.    Anatomical predisposition

8.    Repeated heavy lifting or high impact sports (cross-fit, running, sports that involve a lot of jumping)

 How can physical therapy help with SUI? The theoretical basis for physical therapy to treat SUI is to improve pelvic floor muscle function by increasing strength, coordination, speed and endurance in order to maintain an elevated position of bladder neck during raised intra-abdominal pressure with adequate urethral closure force. A strong contraction of the levator ani muscles within the pelvic floor will help improve urethral closure and support the pelvic organs. By contracting the muscles, the urethra will be compressed and stop urine leakage if the contraction is strong enough and performed at the right time.

So in conclusion, leaking urine at any time is not acceptable! You can do something about it, and why not? What are you waiting for? Schedule an appointment with a pelvic floor physical therapist today!