Stress Urinary Incontinence

These notes are for use together with the Colley Model.

AN OVERVIEW OF STRESS URINARY INCONTINENCE (SUI)

SUI occurs when the urethral sphincter mechanism is weakened and leakage occurs when intra-abdominal pressure is raised. The leakage is usually slight, but can be moderate or in some cases, severe. SUI is common in women. It also may occur in men following prostate surgery, especially radical prostatectomy for prostate cancer.

In simple terms, the pelvic floor muscles (PFM’s) become stretched or weakened and are unable to contract sufficiently to maintain an adequate closure of the urethral sphincter mechanism, to prevent urine leakage when the pressure in the abdomen is increased. Reasons for the PFM’s to be weakened include in women, childbirth, chronic straining as a result of constipation or pressure from a chronic cough. More rarely, weakness of the PFM’s can be congenital or as a result of general muscular or neurological conditions.

The ‘after dribble’ in men
In men, leaking a small volume of urine after emptying the bladder can be a common problem. This is due to urine remaining in the urethra (the tube which carries urine from the bladder through the penis). This problem is usually due to weak PFM’s and can easily be managed (refer to starred box Stress Urinary Incontinence, Treatment), but must not be confused with leakage due to voiding symptoms (refer to notes under blue box 14).

CONTRIBUTING FACTORS IN STRESS URINARY INCONTINENCE (SUI)

Multiparity
There is a higher risk of SUI following pregnancy and childbirth however, nulliparous women CAN suffer SUI.

Constipation
Prolonged straining at stool can cause SUI and can lead to muscle and / or nerve damage.

Obesity
Being overweight may increase the risk of SUI by increasing pressure on the pelvic floor.

Cough
A chronic cough may exacerbate leakage in SUI.

Menopause
SUI may be more noticeable when oestrogen levels fall and the vaginal and urethral mucosa is less moist.

Side-effects of medication
For example, medication such as an alpha blocker used to treat high blood pressure. This medication relaxes smooth muscle, therefore relaxes the smooth muscle at the bladder neck and may result in a weakening of the urethral closure mechanism and SUI in women. (Alpha blockers are also used to treat men who have difficulty passing urine due to an enlarged prostate gland).

Surgery
Some surgical procedures carry a risk of SUI. These include pelvic and vaginal surgery in women and prostate surgery in men.

References:
In women, refer to:
NICE Guideline [NG123] Published date: April 2019. Urinary incontinence and pelvic organ prolapse in women: management
Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline [NG123]. Read it here.

In men, refer to:
NICE Guideline [NG131] Published date: May 2019. Prostate cancer: diagnosis and management.
Prostate cancer: diagnosis and management. NICE guideline [NG131]. Read it here.

TREATMENT FOR STRESS URINARY INCONTINENCE (SUI)

Ideally, the patient should be referred for further specialist examination and advice. If the patient does not wish to be referred at this stage, then explaining how to carry out pelvic floor muscle training (PFMT) is the basic, essential, first line treatment. Written information on how to carry out PFMT may be given. Try to ensure any written information is approved by your local Bladder & Bowel service or Physiotherapy specialists. There are also useful short videos available online on carrying out PFMT.

Always inform the patient of specialist services available if the initial treatment does not result in an improvement in the symptoms.

Constipation
Prevent and/or treat constipation (NICE, 2019). Straining and pushing down onto the pelvic floor will weaken these muscles further. Check for medication contributing to constipation and ensure the correct position on the toilet is adopted when opening the bowels
Download Correct Position For Opening Your Bowels here.

Chronic cough
Advise on medical assessment if a chronic cough has not previously been assessed. If the patient smokes, offer referral for advice on smoking cessation.

Obesity
Advise weight loss if BMI is over 30 kg/m2. (NICE, 2019)

Post-menopausal women
Refer for possible oestrogen replacement or other treatment in women with vaginal symptoms if indicated. (NICE, 2019)

Pelvic floor muscle exercises – women
It is recommended that a vaginal examination is undertaken by a competent professional to estimate the strength of the pelvic floor muscles, and plan an individual programme for the patient.
Pelvic floor muscle training (PFMT) programmes should comprise at least 8 contractions performed 3 times per day for at least 3 months. If this intervention is beneficial, it should be continued. (NICE, 2019). Download pelvic floor muscle exercises – female here.

Pelvic floor muscle exercises – men
Remember information on PMFT for men will differ slightly to that given to women but is essential when treating SUI and also when managing / remedying the ‘after dribble’. The ‘after dribble’ may also be managed by the man placing his fingertips (three fingers wide) behind his scrotum and applying gentle pressure upwards and forwards to encourage the flow of urine along and down the urethra, while the penis is pointing over the toilet. He should then shake or squeeze the penis in the usual way. This should be repeated once to make sure the urethra is completely empty.
Download pelvic floor muscle exercises – male here.

The ‘Knack’
Use the ‘Knack’. Advise the patient to tighten the pelvic floor muscles before any effort or exertion.

Absorbent products
Absorbent products are not a ‘treatment’ as such but the patient may already be purchasing absorbent containment products as a coping strategy. If so, ensure these are fit for purpose and if not, give general advice about where more suitable products can be purchased from. Some product companies may provide samples before purchase.
View and download Product Information for the NHS and Care Providers here.

For further information on a wide range of products available for users, carers and healthcare professionals, follow this link to the Continence Product Advisor.

Reassessment
Ensure that there is a date documented in the patient’s record to assess the effectiveness of the treatment plan.

References and further reading:

NICE Guideline [NG123] Published date: April 2019. Urinary incontinence and pelvic organ prolapse in women: management. Read it here.

Menopause: diagnosis and management. NICE guideline [NG23] Published date: November 2015 Last updated: December 2019. Read it here.

NICE Clinical Guideline [CG97] Lower urinary tract symptoms in men: management. Published date: 23 May 2010 Last updated: 03 June 2015. Read it here.