Discover what causes those "embarrassing leaks"
Do you leak a little whenever you cough or sneeze or laugh? Or maybe you only leak when your bladder is full and then you cough or sneeze? Perhaps you notice some leaking during sex or when you're exercising – it may be during star jumps, jumping on the trampoline, going for a run or whenever you lift heavy weights, even lifting children or heavy shopping bags?
If you've answered yes to any of these questions, you likely have stress urinary incontinence (SUI). SUI is triggered by an increase in the pressure in your abdomen, such as with a cough, a sneeze, a laugh or exercise, which then puts increased pressure on your bladder and on your urethra, causing a small leak.
If you do have SUI, you are not alone. SUI affects 30-50% of women; no matter how old they are – although it is more common after pregnancy and after menopause. This means every second or third woman you know probably leaks a little too! Even though SUI is so common, it certainly is not "normal". Interestingly, men can also develop SUI – but this is usually only if they've had prostate surgery. The great thing is, SUI can often be managed with pelvic floor strength and coordination exercises with your women's health (or men's health) physiotherapist. But there are some cases where a minimally-invasive surgery may be needed.
Can I stop leaking with stronger pelvic floor muscles?
When we think of stress incontinence, often we immediately think that our pelvic floor muscles must be very weak. So if we have a leak we start practicing our pelvic floor muscle exercises in the hopes that the exercises should stop any incontinence. And sometimes pelvic floor strengthening work really does help. But sometimes it doesn't. Sometimes we get frustrated because we've been practicing and practicing but we just keep leaking. This is why we need to understand WHY we are leaking to really address the issue and decide which treatment will be best.
The 3 types of stress urinary incontinence
There are three main types of SUI and sometimes you can have 2 different types taking place at the same time.
Type 1 and Type 2 SUI are due to urethral hypermobility. This relates to the support of the urethra and involves the pelvic floor muscles as well as the connective tissue inside the pelvis. Imagine the connective tissue to be like tight elastic bands that hold the bladder, uterus and bowel in their places inside the pelvis. These tight elastic bands hold the organs to the top of the pelvis, to the sides of the pelvis, to the front and back of the pelvis – there's tight elastic bands everywhere even between the organs and between the urethra and vagina.
There is a sheet of elastic tissue that goes between the pubic bone towards the vagina and completely surrounds the urethra. It is the highlighted bit in the picture above. In SUI this connective tissue is damaged and so rather than holding tight when there is a high pressure (such as a cough or sneeze) the tissue sags, which then makes the urethra drop usually taking the bladder neck with it. This extra movement of the urethra allows for a small amount of urine to escape just at the time of the increased pressure of the cough or sneeze.
In milder cases of SUI due to urethral hypermobility, pelvic floor strength and coordination exercises will help. You can coordinate your pelvic floor to squeeze and lift very strongly and tightly just before the cough and sneeze. This is called The Knack. The pelvic floor muscle supports the urethra by tensioning another sheet of connective tissue to stop any urine from escaping.
Your women's health physiotherapist can prescribe exercises for you. Sometimes a support device called a pessary can be inserted vaginally to support the urethra – these can be fitted by your women's health physiotherapist. In some cases, a key-hole surgery may be required to insert a mesh sling to hold the urethra in place to prevent the hypermobility – essentially replacing the role of the sagging connective tissue. This is called a TVT or a TOT. Your women's health physiotherapist will refer you to a gynaecologist if this is required.
Type 3 SUI is due to urethral sphincter deficiency. In the picture below we can see that the urethra has an internal urethral sphincter and an external urethral sphincter, which act to keep the urethra closed. These sphincters are made of muscle, and with age and particularly after menopause there can be a loss of muscle fibres in the urethra, which can leave the urethra open. There can also be changes to the nerves or blood supply to the urethra with age.
During birth, if the delivery involved instruments such as forceps, there can be some nerve damage which can lead to urethral sphincter deficiency. Previous surgery in the area can also increase the likelihood that it is Type 3 SUI, as there can be nerve or blood supply changes. This is the type of SUI usually found in men after prostate surgery.
Type 3 SUI cannot be completely treated with physiotherapy but can certainly be diagnosed by a women's health physiotherapist. If your physiotherapist believes you have a sphincter issue, you will be referred on to a gynaecologist. Treatment usually involves injecting bulking agents into the urethra to increase the muscle fibres or using medications that can improve the nerve supply or vaginal oestrogen to improve blood supply or nerve regeneration. In some women, a TVT operation will help.
Now that you know WHY you are leaking and HOW stress incontinence occurs you can better understand when pelvic floor exercises can help and when they are not enough. SUI is multifactorial – yes there may be some muscle involvement (which is when pelvic floor muscle exercises do help) but there can also be issues with the connective supporting tissue or with the urethra itself. If you have SUI it is important to know whether it is a urethral hypermobility issue or whether it is an intrinsic sphincter deficiency or whether you have both. Your women's health physiotherapist can help you figure out which it is and advise you of the appropriate treatment.