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After giving birth to your baby you may have to buy diapers for yourself as well as your newborn! Today’s entry discusses the issue of stress urinary incontinence (SUI) and conservative means of management.
SUI affects one in three females during their lifetimes, most often young or middle-aged, although it can happen at any age. A spurt of urine leaks during sudden increases in abdominal pressure, e.g., coughing, sneezing, laughing, jumping, and exercise. It can even happen when walking, changing position, or during sex. The trigger that most consistently provokes SUI is vertical deceleration, e.g., jumping jacks, trampoline and jumping rope.
SUI occurs because of a weakened urethra as well as weakened urethral support that no longer provides an adequate “backboard.” The key inciting factors 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 C-section.
Factors that further promote SUI are weight gain, aging, menopause, gynecological surgery (especially hysterectomy), and conditions that increase abdominal pressure, e.g., coughing (often from smoking), asthma, weight training, high impact exercises, and occupations that require heavy physical labor. Chronic constipation (bowel “labor”) is a major factor because of daily straining, cumulatively causing the same damage as happens with obstetrical labor.
There are no effective medications to treat SUI. However, there are numerous means of managing SUI and the treatment approach needs to be tailored to the needs of the individual. It is sensible to initially use non-invasive options that have minimal side effects. If conservative means fail to improve the SUI, surgical options (urethral bulking agents, slings, etc.) can be highly successful, not the topic of today’s entry.
The Importance of the Backboard
A deficient backboard underlying the urethra is one of the key factors in the occurrence of SUI. Think about a garden hose gushing water. If you try to stop the flow by standing on the hose with sand as a backboard (a deficient backboard) it is difficult to compress the hose and stop the flow. However, if you stand on the hose with solid pavement as a backboard, it is easy to compress the hose and stop the flow. It is the intact backboard that allows compression and closure of the urethra as it is pinched between the pressure of the sudden increase in abdominal pressure and the backboard, allowing the top and bottom walls of the urethra to touch each other (coapt).
Marshall test: With legs in stirrups and a somewhat full bladder, you are asked to cough and see if the SUI can be witnessed. If so, gentle mid-urethral anterior (upper wall) vaginal support is applied with a finger, supporting but not compressing the urethra. If the SUI is aborted, it bodes well for the effectiveness of an incontinence vaginal insert or mid-urethral sling.
Behavioral Strategies to Improve SUI
· Manage the trigger: Treat the asthma that causes wheezing; seasonal allergies that cause sneezing; bronchitis, sinusitis, or post-nasal drip that cause coughing.
· Moderation of fluid intake: The fuller the bladder, the more dramatic the SUI, so not overdoing it with fluid consumption can potentially improve the SUI. Easy on caffeinated beverages and alcohol.
· Urinate regularly: SUI tends to be worse when there are greater volumes in the bladder, so by emptying the bladder more frequently, SUI can be better controlled. Empty your bladder before any activity likely to trigger the SUI.
· Maintain a healthy weight: Extra pounds can worsen SUI by increasing abdominal pressure and placing a greater load on the pelvic floor and bladder.
· Exercise: Physical activity can help maintain general fitness and improve SUI. Exercises that emphasize the core muscles — particularly Pilates and yoga — are most helpful for SUI.
· Tobacco cessation: Eliminate tobacco that causes bronchial irritation and coughing.
· Maintain bowel regularity: A full rectum puts internal pressure on the bladder and urethra. To promote healthy bowel function, exercise daily and increase fiber intake by eating whole grains, fruits, and vegetables.
Pelvic Floor Muscle Training (PFMT) to Improve SUI
Also known as Kegel exercises, PFMT can cure or considerably improve 60-70% of women with SUI. The benefits persist for years if the exercises are adhered to on an ongoing basis. PFMT is most effective in women with mild or mild-moderate SUI. If not cured, the SUI can be improved, and that might just be sufficient.
The goal of PFMT is to increase pelvic floor muscle strength, power, and endurance to improve urethral support and closure. The training is put into practical use (Kegels on demand) by contracting the pelvic floor muscle prior to trigger exposure, e.g., immediately prior to a sneeze, cough, or positional change, effective “clamping” the urethra to prevent or lessen the leakage.
I give all new patients suffering with SUI a copy of my book The Kegel Fix.
Incontinence Vaginal Devices to Improve SUI
Many patients are content with having their medical issue managed conservatively, avoiding incurring risks or complications from an invasive procedure. For example, I am nearsighted and am content with wearing contact lenses and avoiding a laser eye procedure. I wear the contacts during the day and remove them at night while sleeping, when they are not needed. Similarly, not all women need or desire an operative cure for SUI that can alternatively be managed non-invasively.
If SUI occurs under predictable circumstances — e.g., during tennis, golf, jogging, exercise class, etc. — a strategically placed vaginal insert can mechanically support the urethra, the same mechanism as a urethral sling. By positioning the device in the vagina directly beneath the urethra, it occupies space and functions as a backboard.
There are several different vaginal insert devices available to manage SUI. These are referred to as either incontinence tampons or pessaries. They are easy to insert and remove and are designed to be worn during trigger activities, or alternatively, to be worn all day long, but removed for sleep. Most are relatively inexpensive. They are listed below in alphabetical order:
This is a single-use, bullet-shaped vaginal pessary that is available in three sizes.
Contiform Incontinence Pessary
Available in Australia and the UK, this self-inserted, soft, flexible, foldable, reusable (for up to one-month) intravaginal device is shaped like a hollow tampon. It comes in three sizes and is moistened with water to insert and can be easily removed for cleaning. An optional removal device facilitates easy removal.
This silicone device that comes in three sizes consists of a handle that remains outside of the vagina and an internal support.
Poise provides this non-absorbent incontinence tampon that is available in three sizes. It is a single-use device placed via an applicator that has a string like a standard tampon and can be worn for up to eight hours. The tampon does not need to be positioned as deeply as it would be for menstruation, but just within the vagina, so that it sits directly under and provides support to the urethra.
Milex incontinence ring pessary
Although pessaries are traditionally used for pelvic organ prolapse, (graphic image included for medical purposes) some are designed for SUI and some for both SUI and pelvic organ prolapse. This reusable ring-shaped device has a knob for urethral support.
This is a self-inserted, one-size-fits-all, reusable (for up to one month) intravaginal device.
Uresta Last in alphabetical order, but certainly not the least!
Developed by a Canadian urogynecologist, this reusable (for up to one year), washable insert comes in 5 different sizes.
Minerva provided me with a patient demonstration Uresta model that I showed to several nurses and medical assistants whom I work closely with. The collective initial impression was ouch, this would be uncomfortable to wear. I reached out to our Minerva representative who denied that comfort is an issue with this device. Upon my request, she provided me with several sample devices so that I could have patients trial the Uresta and provide me with honest feedback. Two nurse patients were kind enough to trial the device. One was multiparous (several vaginal deliveries) and had SUI, and the other was nulliparous (no children) and did not have SUI. I was interested in how effective and how comfortable this device was, particularly in a woman whose anatomy had not been altered by childbirth. The answer from the multiparous nurse: “The Uresta was effective in alleviating the SUI and not uncomfortable.” The answer from the nulliparous nurse: “The Uresta was comfortable.” Ladies and gentlemen, we have a winner here! Going forward, I will recommend this device as a conservative means of management to any patient I see with SUI, to be used in conjunction with behavioral strategies and pelvic floor muscle training.
