Andrew Siegel MD 2/25/17
*Credit for title “Leaking Havoc” goes to freelance writer Karen Gibbs who recently interviewed me for an article on this topic for New Jersey Family Magazine.
Stress urinary incontinence (SUI) is a very common condition that affects one in three women during their lifetimes, most often young or middle-aged, although it can happen at any age. An involuntary spurt of urine occurs during sudden increases in abdominal pressure, which can happen with coughing, sneezing, laughing, jumping or exercise. It can even happen with walking, changing position from sitting to standing, or during sex.
Illustration above of stress urinary incontinence, by Ashley Halsey from Dr. Siegel’s book : “The Kegel Fix”
In Europe, SUI is referred to as “exertion” incontinence, since some form of physical effort usually triggers it. This is less confusing than the American term “stress” incontinence since the word stress is most typically used in the context of emotional stress–but here I am referring to only the physical stress of a sneeze, jump, etc.
Who Knew? The triggers that most consistently provoke SUI are jumping up with a sudden stop as one’s feet touch down—jumping jacks, trampoline and jump rope.
Who Knew? There are hereditary/racial differences in the prevalence of SUI with SUI being less common in women of African-American descent and more common in Caucasian women, thought to be on the basis of genetic differences in pelvic muscle bulk.
SUI most often occurs because the support to the urethra (the urinary channel that goes from the bladder out)—the pelvic floor muscles and connective tissues—has weakened and no longer provides an adequate “backboard” to the urethra. This allows the urethra to be pushed down and out of position at times of sudden increases in abdominal pressure, a condition known as urethral hyper-mobility.
The key inciting factors for SUI are pregnancy, labor and delivery, particularly traumatic vaginal deliveries of large babies. SUI is uncommon in women who have not delivered vaginally or in women who have delivered by elective Caesarian section (a C-section without experiencing labor). However, emergency C-section done for failure of labor to progress has a similar risk for SUI as vaginal delivery.
Many women experience SUI during pregnancy. By their third month of pregnancy, 20% of women report SUI, as do 50% at full term. There are many reasons for its occurrence, including the pressure of the enlarging uterus on the bladder and stretching of the pelvic floor muscles and other connective tissues.
Who Knew? After giving birth to your newborn, in addition to buying diapers for your baby you may have to buy them for yourself!
Who Knew? The more vaginal deliveries one has, the greater the likelihood of developing SUI.
Who Knew? Numerous studies have demonstrated the benefits of pelvic floor muscle training (Kegels) in facilitating an early return of urinary control and improving the severity of SUI.
Some women experience persistent SUI after childbirth, while others find that it improves dramatically and resolves within 6 months. Others will not experience SUI until many years after childbirth, after promoting factors have kicked in. These factors include obesity, aging, menopause, weight gain, gynecological surgery (especially hysterectomy), and any condition that increases abdominal pressure. These include coughing (often from smoking), asthma, weight training and high impact sports (e.g., trampoline, gymnastics, pole vaulting, etc.) and occupations that require heavy physical labor. Chronic constipation is a major contributory factor because of pushing and straining on a daily basis, cumulatively causing the same weakening of urethral support as happens with obstetrical labor.
Who Knew? SUI is common in recreational as well as elite female athletes, particularly those who participate in high impact sports involving jumping. It can lead to poor athletic performance and ultimately avoiding sports participation.
The specific activities that provoke SUI and the severity of the leakage can vary greatly from woman to woman. Some only experience SUI with extreme exertion, such as when serving a tennis ball, swinging a golf club or with a powerful sneeze. Others experience SUI with minimal exertion such as walking or turning over in bed. Some women do not wear any protective pads or liners, changing their panties as necessary, whereas others wear many pads per day. Some are significantly bothered by even a minor degree of SUI, while others are accepting of experiencing many episodes of SUI daily.
Although the predominant cause of SUI is inadequate urethral support, it may also be caused by a weakened or damaged urethra itself. Risk factors for this are menopause, pelvic surgery, injury to the urethral nerve supply, radiation, and pelvic trauma. Such a severely compromised urethra usually causes significant urinary leakage with minimal activities and also results in “gravitational” incontinence, a profound urinary leakage that accompanies positional change.
Genuine SUI needs to be distinguished from other conditions that cause leakage of urine with increases in abdominal pressure that are not on the basis of inadequate urethral support or a weakened urethra. These other conditions can masquerade as genuine SUI. It is critical to distinguish between them since the treatments are very different. This is one reason why a thorough evaluation of SUI is important. The conditions that can masquerade as genuine SUI include: failure to empty the bladder; urethral diverticulum; vaginal voiding; and stress-induced involuntary bladder contraction.
Failure to empty the bladder can occur for a variety of reasons, including blockage of outflow of urine and an underactive bladder that contracts poorly. When the bladder is constantly full, it is easy to understand why a sudden increase in abdominal pressure can provoke leakage.
Who Knew? An extension of this is that if your bladder is full and you leak a small amount with jumping or laughing, it is not necessarily problematic, but just means that you need to urinate before engaging in such activities.
Urethral diverticulum is a small sac-like out-pouching from the urethra that can fill up with urine and leak during physical activities. The treatment is often surgical repair.
Vaginal voiding occurs in a small percentage of women who have an anatomical variation in which their urethral openings are internally recessed as opposed to the normal external urethral opening on the vestibule, immediately above the vaginal opening. When urinating, some of the urine pools in the vagina. Upon standing and physical exertion, the urine can then leak out of the vagina.
Stress-induced involuntary bladder contraction is a condition in which an involuntary contraction of the bladder (the bladder squeezing without its owner’s permission) is triggered by a maneuver that typically causes SUI. For example, a cough induces an involuntary bladder contraction, causing urinary leakage.
…To be continued next week when I will review how to diagnose and treat SUI.
Wishing you the best of health,
A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com
Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.
Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com
Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health http://www.TheKegelFix.com. Much of the content of this entry was excerpted from this book, written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.
The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.