Stress urinary incontinence

Clinical presentation
Stress urinary incontinence (SUI) refers to involuntary voiding during states of increased
intra-abdominal pressure, such as when one is coughing, sneezing, and engaging in physical
activity. Although SUI can occur in both males and females, the female population is at higher
risk due to their pelvic anatomy. SUI is the result of an imbalance between the intraurethral and
intravesicular pressures that is accentuated in states of increased intra-abdominal pressure.
Normally, increases in intra-abdominal pressure are equally dispersed onto the bladder and
urethra, so the intravesicular and intraurethral pressure difference is negligible.
When intra-abdominal pressure is not equally dispersed onto both bladder and urethra,
SUI may be the result. Unequal pressure dispersion is usually secondary to either an intrinsic
sphincter deficiency (rare) or a hypermobile urethra that results from weakening of the pelvic
floor muscles (more common). The typical presentation of SUI is painless voiding at times of
increased intra-abdominal pressure without urgency to void.
Work-up
The work-up of urinary incontinence (UI) in women first involves determining whether
the incontinence is complicated by other signs/symptoms (hematuria, neurological symptoms,
abdominal pain, pelvic abnormalities) and addressing those complications. If UI is
uncomplicated, then it needs to be evaluated whether the incontinence is secondary to another
factor, such as a medication side effect or a UTI, with appropriate management of the secondary
factor. If UI is not secondary to another factor or still continues despite appropriate management,
the type of UI (stress, urgency, stress/urgency, overflow, or bypass) must be determined. This
step is primarily a clinical diagnosis but diagnostic tests exist. Briefly, urgency UI is secondary to
detrusor muscle overactivity, overflow UI is secondary to a hypotonic/atonic bladder, and bypass
UI is secondary to a vesiculo-vaginal or uretero-vaginal fistula.
Although SUI can be a clinical diagnosis, diagnostic tests are available. The cough stress
test evaluates for urinary leakage in a state of increased intra-abdominal pressure. The test
involves the patient have a full bladder, be in a lithotomy or standing position, and cough, while
the examiner inspects for urine leakage. The cotton swab test evaluates for urethral
hypermobility. In this test, a cotton sab is inserted through the urethra to the level of the
urethrovesicular junction and the patient is then asked to strain as if she were urinating. A change
in the cotton swab angle from baseline (resting) of > 30 degrees suggests urethral hypermobility.
Cystometric testing can diagnose urethral sphincter function by measuring intravesicular and
intraurethral closing pressures upon straining.
Management
After a diagnosis of stress UI is made, the primary treatment is lifestyle modification that
includes weight loss, fluid management/bladder training, caffeine restriction, and pelvic floor
muscle strengthening (Kegel exercise). If incontinence is improved, a continuation of these
lifestyle changes is advised. If incontinence is not improved, secondary intervention involves
incontinence pessaries or (if still unresolved) surgical intervention.
An incontinence pessary is a device placed intravaginally to help support the urethra. As
pessaries are foreign bodies, they pose a risk for infection and damage to vaginal epithelium.
Topical estrogen is concurrently prescribed to decrease vaginal tissue damage. Surgical

interventions include either a Burch procedure (urethropexy to the pubic bones), placement of
bladder neck sling (elevates the urethra), or placement of tension-free midurethral sling (supports
the midurethra). If an intrinsic sphincter deficiency is the cause of the SUI, intervention involves
periurethral bulking, commonly with collagen injections. Although medications such as alphaagonists (phenylpropranolamine) or SNRIs (duloxetine) have been historically attempted prior to
surgical intervention, they possess an array of side effect profiles and do not have supporting
evidence for their use.
References
Hacker,NevilleF.,JosephC.Gambone,andCalvinJ.Hobel.Hacker&Moore'sessentialsof
obstetricsandgynecology.Philadelphia,PA:Elsevier,2016.Print.
Treatmentofurinaryincontinenceinwomen.UpToDate.
https://www.uptodate.com/contents/treatmentofurinaryincontinenceinwomen?
source=search_result&search=stress+urinary+incontinence&selectedTitle=2~64.
AccessedonSep1,2016.