Stress Urinary Incontinence

Stress urinary incontinence is a common condition where everyday movements like coughing, laughing, or exercising cause unwanted urine leakage. While it can feel embarrassing, effective treatments exist—from simple lifestyle changes to specialized exercises and, when needed, medical procedures.

Table of contents

• What is stress urinary incontinence
• Who is affected
• Symptoms and when they occur
• Causes and risk factors
• How doctors diagnose the condition
• Treatment options
• Lifestyle changes and self-help
• Pelvic floor muscle training
• Medical and surgical treatments
• Impact on daily life

What is stress urinary incontinence

Stress urinary incontinence occurs when your bladder leaks urine during physical activity or exertion. This happens when movement or activity puts pressure on the bladder, causing urine to leak^[1]. The condition gets its name from the physical “stress” or pressure placed on the bladder, not from mental or emotional stress^[1].

This type of incontinence is different from urgency incontinence (also called overactive bladder), which involves a sudden, intense urge to urinate. Stress incontinence involves leakage without that urgent feeling—the physical pressure on your bladder simply forces urine out^[1].

Stress urinary incontinence is the most common type of urinary incontinence. It affects millions of people globally and significantly impacts their quality of life^[3][4].

Who is affected

Stress incontinence is much more common in women than in men^[1][4]. It affects twice as many women as men, and about one out of every two women aged 65 and older experiences this condition^[4]. As many as 37 in 100 women will experience stress urinary incontinence at some point in their lives^[4].

In women, more than 60% experience urinary incontinence during their lifetime, with higher rates among those who have had children. The condition becomes more common with age^[3]. Although it can occur in men after prostate surgery, it is most prevalent in women, particularly those who have undergone multiple vaginal childbirths, menopause, or pelvic surgery^[3].

Despite how common it is, many people feel embarrassed and hesitate to seek medical help, leading to underdiagnosis and inadequate management^[3]. However, this is not a normal part of aging—it is a sign of a problem that can improve with the right treatment^[4].

Symptoms and when they occur

The main symptom of stress incontinence is leaking urine during activities that put pressure on your bladder^[2]. You may notice leakage when you:

• Cough or sneeze
• Laugh
• Exercise or engage in physical activity
• Lift heavy objects
• Stand up from a sitting or lying down position
• Jump or run
• Have sex^[2][4]

The amount of leakage can vary. With mild stress incontinence, you may leak just a few drops of urine while laughing, coughing, sneezing, squatting, or doing heavy exercise. If you have moderate or severe stress incontinence, you may leak more than a tablespoon of urine during less strenuous activities, like bending over or standing up^[4].

For many people, you may not feel like you have to urinate beforehand. Instead, an activity or movement suddenly causes you to leak urine, which you may feel dribbling out^[4].

Causes and risk factors

Stress incontinence occurs when the tissue that supports your urethra (the tube that carries urine from your bladder to the outside) gets weak^[2]. The bladder and urethra are supported by the pelvic floor muscles. The urinary sphincter is a muscle around the opening of the bladder that squeezes to prevent urine from leaking through the urethra. When either set of muscles becomes weak, urine can pass when pressure is placed on your bladder^[2].

The primary causes of stress urinary incontinence in women are the weakening of the pelvic floor muscles and connective tissues supporting the bladder and urethra. Intrinsic sphincter deficiency (when the sphincter cannot close properly) is the other major cause^[3].

Weakened pelvic floor muscles may be caused by:

• Childbirth (especially vaginal delivery)
• Pregnancy
• Injury to the urethra area
• Some medicines
• Surgery in the pelvic area or the prostate (in men)
• Being overweight
• Unknown causes^[2]

Several factors increase your risk for stress incontinence:

• Being 65 or older
• A body mass index (BMI) greater than 25 (having overweight or obesity)
• Chronic (long-term) constipation
• Chronic cough
• Diabetes
• Menopause
• Pelvic floor muscle weakness
• Smoking
• Uterine prolapse^[4]

Delivering a baby can cause nerve or tissue damage in the pelvic area. This can lead to pelvic prolapse months or years after delivery, where the bladder, urethra, or rectum slide into the vagina^[2].

How doctors diagnose the condition

Your healthcare provider will perform a physical exam, which will include a genital exam in men, a pelvic exam in women, and a rectal exam^[2]. Before your appointment, a provider may ask you to keep a bladder diary for a few days where you track how much you drink, when you urinate, and when you leak^[4][7].

During your visit, your appointment will likely include:

• A voiding diary review
• Medical history
• Physical exam (including pelvic or rectal exam)
• Test of a urine sample for infection or traces of blood
• Brief neurological exam to see how the pelvic nerves work
• Urinary stress test, in which your healthcare professional looks for urine loss when you cough or bear down with a full bladder^[7]

Additional tests may include:

• Cystoscopy to look inside the bladder
• Pad weight test, where you exercise while wearing a sanitary pad that is then weighed to find out how much urine you lost
• Pelvic or abdominal ultrasound
• Post-void residual (PVR) to measure the amount of urine left after you urinate
• Urinalysis to check for urinary tract infection
• Urodynamic studies to measure pressure and urine flow
• X-rays with contrast dye to look at your kidneys and bladder^[2]

Common cases of urinary incontinence often don’t need extensive testing. However, sometimes your healthcare professional might order tests to see how well your bladder, urethra, and sphincter work^[7].

Treatment options

Treatment depends on how your symptoms affect your life. There are three main types of treatment for stress incontinence: behavior changes and bladder training, pelvic floor muscle training, and surgery^[2]. Initial treatment should include a review of conditions and medications that may be aggravating the problem^[13].

A stepped-care approach that advances from least invasive (behavioral modification) to more invasive (surgery) interventions is recommended^[10]. Conservative therapies should be the first-line treatment for stress urinary incontinence^[10].

There are currently no medications approved by the U.S. Food and Drug Administration specifically for the treatment of stress incontinence^[2][13]. Some providers may prescribe a medicine called duloxetine, but this medicine is not approved by the FDA for this purpose^[2].

Lifestyle changes and self-help

Making simple lifestyle changes can help manage symptoms. These changes may include:

Weight management: Losing excess weight can help. Being overweight weakens your pelvic floor muscles and causes incontinence because of the pressure of fatty tissue on your bladder. Your symptoms may improve, and could go away completely, if you lose any excess weight^[5][13]. On average, losing 10% of body weight produces a 50% improvement in both stress and urgency urinary incontinence in women who are overweight or obese^[15].

Quitting smoking: Smoking can reduce coughing and bladder irritation. It also increases your risk for bladder cancer^[2][18]. Smoking nearly doubles the likelihood that a woman will develop stress incontinence, perhaps because it can lead to frequent and vigorous coughing^[15].

Managing constipation: Taking fiber to avoid constipation can help, as constipation can make stress urinary incontinence worse. Straining to have a bowel movement weakens your pelvic floor muscles^[2][18].

Adjusting fluid intake: Drink less fluid if you drink more than normal amounts. Avoid drinking water before going to bed^[2]. Drink 6 to 8 glasses of fluid a day (but no more) unless your doctor advises you otherwise. Not drinking enough fluid can make incontinence worse because it reduces your bladder’s capacity^[18].

Avoiding bladder irritants: Avoid alcohol and caffeinated drinks such as coffee, as they can make your bladder fill up quicker^[2]. Cut down on caffeine, which is found in tea, coffee, and cola, as it can increase the amount of urine your body makes^[9]. Caffeine is a diuretic that results in rapid filling of the bladder. Drinking just two cups of coffee per day has been linked to a higher risk of urinary incontinence^[15]. Also avoid spicy foods, carbonated drinks, and citrus^[2][18].

Activity modifications: Avoid jumping or running if these activities trigger leakage^[2]. High-impact exercises and sit-ups put pressure on your pelvic floor muscles and can increase leaks. To strengthen your pelvic floor, replace high-impact exercise with strengthening exercise such as pilates^[18].

If you have diabetes, keep your blood sugar under good control^[2].

Pelvic floor muscle training

Pelvic floor muscle exercises are considered first-line treatment for stress incontinence^[10]. Your pelvic floor muscles surround the bladder and urethra and control the flow of urine as you urinate. Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended^[9].

Kegel exercises (voluntary contractions of the pelvic floor muscles) done regularly and with the proper technique have been shown to be successful at managing stress incontinence^[13]. These exercises can help keep the muscle around your urethra strong and working well, which may help keep you from leaking urine^[2].

To do pelvic floor exercises:

• Squeeze your pelvic floor muscles quickly—try not to pull your tummy in
• Hold the squeeze for 2 seconds
• Relax the muscles
• Repeat 10 times
• Breathe normally and relax while doing the exercises^[18]

Your program should include a minimum of 8 muscle contractions at least 3 times a day and last for at least 3 months. If the exercises are helping after this time, you can keep doing them^[9]. You may have to do pelvic floor exercises for a few months before you see any benefits^[18].

Supervised pelvic physical therapy with the use of biofeedback (a method that helps you learn to identify and control your pelvic floor muscles) or the use of vaginal weighted cones can also improve symptoms^[2][13].

Vaginal cones are small weights that you place into the vagina and then try to squeeze your pelvic floor muscles to hold in place. You can wear the cone for up to 15 minutes at a time, twice a day^[2]. Some women find vaginal cones uncomfortable or unpleasant to use, but they may help with stress incontinence^[9].

Electrical stimulation may be recommended if you’re unable to contract your pelvic floor muscles. A small probe is inserted into the vagina, or into the anus (if you have a penis). An electrical current runs through the probe, which helps strengthen your pelvic floor muscles while you exercise them^[9].

Medical and surgical treatments

The use of pessaries has been shown to be successful about 50% of the time. Success with pessaries tends to be in patients whose stress incontinence is related to specific activities, who can use a pessary to resume the activities without leaking urine^[13].

When stress incontinence is associated with vaginal atrophy, local estrogen treatment has been shown to improve symptoms. It may take up to twelve weeks for patients to notice a benefit^[13].

For patients with intrinsic sphincter deficiency, injection of bulking agents into the proximal periurethral tissue (the area around the urethra) may be used. These agents may also be used for genuine stress incontinence in women in whom operative intervention may be especially hazardous, as second-line therapy after surgery has failed, or when incontinence persists with a non-mobile bladder neck^[13].

Surgical treatment should be considered in women with stress incontinence that has not responded to less invasive treatment modalities^[10]. Surgery may be reserved for stress incontinence that has not responded to other treatments^[10]. If patients continue to have bothersome symptoms following non-surgical management, surgical interventions may be recommended, and high cure rates can be achieved^[13].

Surgical treatment for stress incontinence, such as a sling procedure, is used to reduce pressure on the bladder or strengthen the muscles that control urination^[5].

Impact on daily life

Stress incontinence can be embarrassing and cause anxiety or depression. Absorbent underwear and urinary pads can catch leaks, but you may worry that others can notice you’re wearing them or be self-conscious about odors. This may prevent you from going out in public or being far from a restroom^[4].

Many people feel embarrassed and limit their work and social life because they don’t want to experience leakage^[1]. Patients are particularly embarrassed by the odor from the liberated urine. Often patients will restrict water intake to maintain low urine volumes, thereby reducing incontinence episodes. Secondary effects may include skin excoriation or fungal skin infections^[6].

Long-term exposure to urine can also irritate your skin, leading to a skin rash and sores^[4].

It’s important to see a healthcare provider if you have any type of urinary incontinence. You should not feel embarrassed talking about your symptoms. This can be the first step towards finding a way to effectively manage the problem^[5].