▷ Overview
Involuntary loss of urine is reportedly experienced by upwards of 95% of women in their reproductive and post-menopausal years. This, however, does not mean that this overwhelming majority has urinary incontinence. To qualify as urinary incontinence (UI), the involuntary loss of urine must have a negative impact on the quality of the individual`s life, particularly for hygienic and/or social standpoints. As such, the only person who can ultimately determine the presence of UI is the woman herself.


If you or someone you know is affected by loss of bladder control, you are not alone. An estimated 15-20 million people in the United States have bladder control problems. This condition affects men and women, although it is nearly twice as common in women. The prevalence of this condition does increase with age. 15 to 30 percent of adults greater than 60 years of age have UI. However, this condition should not be considered a normal result of aging.


Urinary incontinence is often caused by specific changes in body function due to related or unrelated diseases and/or usage of medications that affect function of the urinary tract (e.g., diuretics or "water pills," anti-hypertensives or “blood pressure pills”). More often than not, UI is more of an annoyance than a sign of a life-threatening condition. Despite the high prevalence, most people with UI are reluctant to seek help. They might be embarrassed to acknowledge that they have a problem, even to themselves. Or, they might have broached the issue with family members, acquaintances, and/or friends who were discouraging or suggested that no truly useful remedies exist. Thus, many sufferers resort to dealing with the progressively worsening leakage by using the many absorbent products available, including pads and/or diapers. This resignation often results in emotional and psychological vulnerability, including depression and social isolation. 


There is absolutely no reason for this to happen. The good news is that 80-90% of cases can be treated successfully. Although complete cure may not be attainable in all cases, substantial improvement can be expected in the vast majority. So, if you or someone you know suffers from this condition, be PROACTIVE. Get evaluated and review treatment options appropriate to YOUR UI. The more you know, the more confident you will be in choosing the direction of treatment.


Below, you will find a significant amount of information on the more common causes of female urinary incontinence and associated pelvic organ prolapse (POP) conditions, including causes/predisposing factors, diagnostic evaluation, treatment options and suggestions for obtaining further information.


▷ Types of urinary incontinence
Female urinary incontinence can be grouped in several distinct categories, although women often have symptoms found in more than one category (i.e., mixed incontinence).
• Stress Incontinence : Urine leakage occurs with increases in abdominal pressure (hence, mechanical “stress”). 
• Urge Incontinence : Often referred to as “overactive bladder.” Inability to hold urine long enough to reach restroom. 
• Mixed Incontinence : When two or more causes contribute to urinary incontinence. Often refers to the presence of both stress and urge incontinence. 
• Overflow Incontinence : Leakage or “spill-over” of urine when the quantity of urine exceeds the bladder’s capacity to hold it. 
• Functional Incontinence : Leakage (usually resulting from one or more causes) due to factors impairing reaching the restroom in time because of physical conditions (e.g., arthritis) 


▷ Definition of Stress Incontinence
Stress urinary incontinence (SUI) is loss of urine that occurs simultaneously with (at the same time as) physical activities that increase abdominal pressure (for instance: sneezing, coughing, boisterous laughing, and straining when performing exercises like abdominal "crunches," or lifting objects). Many of the above-described activities lead to increased pressure within the abdominal cavity. This, in turn, increases the pressure within the bladder, which behaves like a balloon filled with liquid. The rise in bladder pressure has a tendency to force the urethra open and urine loss ensues. The amount of urine loss associated with SUI is usually small, ranging from mild seepage to drops to a large squirt.

▷ Normal Function of the Urinary Tract
The urinary tract is made up of the following:
• Kidneys: Two orange-sized organs situated in your back and protected by the rib cage; function to filter blood and produce urine (liquid waste) 
• Ureters: Two thin tubes which deliver urine from the kidneys to the bladder 
• Bladder: Holding tank for urine 
• Urethra: Conduit/valve 


The urethra has two functions: it serves as a pipeline from the bladder to the outside when you empty your bladder; also it is a valve that needs to stay closed in order for your bladder to retain urine.


Abnormalities to the urethra`s closure mechanism are the primary cause of SUI. In most cases, support to the urethra is lacking. The front or anterior wall of the vagina acts as a backboard to the urethra. When you cough, laugh or strain, the pressure rise in the abdomen is transmitted simultaneously to the bladder and to the outside of the urethra. This mechanism compresses the urethra against the underlying front vaginal wall, effectively pinching the urethra closed (valve mechanism) and preventing loss of urine. If the front vaginal wall, especially beneath the urethra is lax and moves too much (urethral hypermobility) the backboard valve mechanism is compromised. In fewer cases, the resistance provided by the urethra itself is low. The tiny muscles (smooth muscle cells) that make up the wall of the urethra lose their ability to maintain adequate resting tone and pressure and/or to squeeze (pressure rise) during stress-related events (e.g., coughing, straining, etc.) In menopausal patients, the once-abundant mucus in the urethral lining diminishes. This compromises the urethra`s ability to seal closed. Any or all of these factors can play a role in the presence of SUI.


▷ Predisposing Factors to SUI
• Gender 
• Genetic: inherited component of connective tissue, connective (supportive tissue and muscle) 
• Vaginal birth trauma 
• Previous pelvic/vaginal surgery 
• Radiation therapy 
• Menopausal status 
• Chronic conditions: respiratory ailments, obesity, constipation, occupation/lifestyle (strenuous lifting) 


In general, the causes of SUI are many. Listed above are factors that lead to SUI. You need to keep in mind that like pelvic organ prolapse, SUI does not result from any one of these factors listed, or from a single event. Instead, a combination of these over a span of many years is most likely involved in the initial development and eventual progression of SUI. Some of the above are self-explanatory and others should be discussed. 


There is little we can do (currently) regarding inheritance of genes for "weak" supportive tissues and muscles. However, if any of your immediate relatives experienced pelvic prolapse conditions or SUI, chances are good for you to develop these problems as well. Obstetricians are becoming more and more aware of the risks of injury to the pelvic floor caused by vaginal delivery. Excessive stretching of the supportive tissues, muscles and nerves, can cause permanent defects even after post-pregnancy healing. This may lead to various pelvic floor support problems for the surrounding organs: bladder (cystocele), rectum (rectocele), and top of vagina and uterus (uterovaginal descensus/ prolapse). Frequently, SUI is present in the period immediately following vaginal delivery. Although the SUI may resolve with time, its initial presentation may signal the development of more troublesome SUI in the future. And the greater the number of vaginal deliveries (2 or more), the greater the chance of POP and SUI in the future.


Previous pelvic/vaginal surgery for prolapse or radiation therapy to the area can lead to worsening urethral function in the future, by interfering with the blood and nerve supplies to this delicate structure. Also, nearby surgeries like hysterectomy (removal of uterus), whether through an abdominal incision or vaginally, can cause injuries to the bladder and/or urethra. Fistulae (an abnormal tract/connection) between the two structures and the vagina can appear like SUI. Chronic conditions that lead to persistently elevated pressures in the abdomen can result or worsen SUI. Lung conditions (bronchial asthma, bronchitis), obesity, constipation, and occupation/ lifestyle situations that involve heavy lifting or straining can lead to SUI. Loss of elasticity is an inevitable part of the normal aging process. This is known to be quickened by loss of estrogen stimulation once estrogen diminishes or ceases after natural or surgical menopause (i.e. removal of ovaries). In addition, decreased estrogen stimulation causes less mucus production by urethral glands, thereby compromising the urethral sealing ability.


▷ Diagnosis
An appropriate evaluation helps your physician or other health-care provider pinpoint the type(s) of urinary incontinence you might have. An exhaustive evaluation is not always necessary - your doctor/provider will determine what components will be important in your case.


Before a physical examination and other tests, your doctor/provider will ask you a series of questions. Your responses will assist your doctor/provider in mapping out the tests that will be utilized. Some of the typically asked questions are listed below (Fig.1). A thorough history will be taken, reviewing your past and more recent medical, surgical and Ob/Gyn history (Fig.2). You will be asked to list your medications (Fig 3). A 1 - 7 day voiding diary recording the amount and time of every void will need to be kept by you and reviewed by your provider.


The physical examination will involve the following:
• Neurologic examination: basic testing of nerves supplying the legs and vaginal opening; the same nerves service the bladder and urethra.
• Pelvic examination: a typical GYN examination to identify pelvic floor defects, including those of the front (cystocele), back (rectocele) and top walls (uterine and/or vaginal prolapse).
• Urine specimen: obtained following voiding to determine how efficiently the bladder empties itself; a specimen is sent for bacterial culture (a urinary infection can cause or worsen urinary incontinence).
• Cystoscopy: the physician looks into the urethra and bladder with a small, illuminated telescope-like instrument to rule out stones, growths and foreign bodies (sutures from previous anti-incontinence surgery).
• Urodynamic studies: these are tests that measure pressures in the bladder and urethra simultaneously to tell how both components are working. They are done in an outpatient clinic, take 30-60 minutes, and are not painful.


Uroflowmetry measures and records the amount and rate (speed) of urine during voiding.


Cystometrogram measures how the bladder operates as it stores larger amounts of urine during filling.


Urethral pressure profile/closure pressure measures urethral pressure to determine the urethra`s effectiveness as a closure valve.


Leak point pressure measures how much pressure it takes to open the urethral sphincter (valve) and allow urine to leak.


Voiding study measures simultaneous pressure changes in the urethra (decrease) and bladder (increase) as bladder empties during voiding.


Please note that you may not need all of the above tests for your healthcare professional to determine the type or cause of your incontinence.

▷ Treatment Options for SUI


Non-surgical
• Absorbent pads/diapers
• Kegel exercises:
Pelvic floor muscles act as a hammock or sling to buttress support to the urethra and bladder during stress related activities; exercising these muscles improves the resting tone and strength of active contractions to help close the urethra when coughing or laughing; innumerable Kegel exercise regimens are used but all have one thing in common: they must be done on a regular basis and indefinitely for the recipient to derive noticeable benefit.
• Pessaries: 
These simple plastic shapes, worn in the vagina, were originally used only for pelvic organ prolapse. However, properly sized and incontinence modified pessaries can provide support beneath the urethra, compensating for the laxity of urethral support found in most SUI situations.
• Special devices: 
Urethral plugs and other devices may be available when the above strategies are unsuccessful.
• Urethral implant: 
Injection into the urethra of sterilized collagen or micro-beads is directed by a telescope-like device (urethroscope) to decrease the size of the gaping urethra. This creates a washer-like effect that assists in closing the urethra during coughing or straining. Unfortunately, more than one injection is usual.


Surgical
Many operations are available to cure SUI. These are intended to restore the support of the front vaginal wall immediately beneath the urethra; thereby enhancing compression of the urethra against the backboard of the front vaginal wall. The Burch, MMK and sling, including TVT (tension-free vaginal tape) use sutures and graft material (natural or synthetic) to provide cure rates as high as 95%, but these must be carefully selected for the specific type of SUI.


▷ Additional information
For more information regarding the treatment of urinary incontinence, please check the following links:


Society of Gynecologic Surgeons : www.sgsonline.org
National Association for Continence : www.nafc.org
American College of Obstetricians and Gynecologists : www.acog.org
American Urological Association ; www.auanet.org
www.obgyn.net


▷ Figure 1 / Symptoms
• How long have you had a leakage problem?
• How often do you urinate?
• How many times at night do you get up to urinate?
• Do you wet yourself when you cough, sneeze, or stand up?
• Do you have to run to the bathroom to avoid wetting yourself?
• Do any foods or fluids make the leakage worse? (List under "other comments")
• Do you use pads to absorb urine leakage?
• If you use pads, how many do you use each day? 
• Do you have burning pain when you urinate? 
• Do you have pain in your lower abdomen or back? 
• Have you recently seen blood in your urine? 
• Does your urine stream dribble and have no force? 
• Do you have any problems with bowel movements? 
• Has your condition gotten worse since it started? 
• Have you been evaluated or treated before? 
• Do you smoke? 
• Are you sexually active? 
• Other comments:


▷ Figure 2 / Medical History
Illness or injury to the back or pelvis 
Surgery to the back, pelvis, or bladder 
Stroke or brain injury 
Nerve disorders (such as Parkinson`s) 
Radiation to the pelvis 
Glaucoma 
Vaginal delivery of children_____ times 
Urinary tract infection within the past 3 months 


▷ Figure 3 / Medications
Diuretics 
High blood pressure medication 
Sleeping pills or tranquilizers 
Hormones 
Antihistamines, decongestants, or cold medicines 
Herbal therapies