Stress Urinary Incontinence (SUI)

Definition:

Involuntary leakage of urine associated with physical activities like coughing, sneezing, laughing, lifting, etc., abruptly raising bladder pressure to exceed the resistance of the urethra sphincter muscle.

Prevalence:

♂ Male - SUI is rare in men; most cases occur post prostatectomy. About 5-20% of men will experience SUI as a complication from prostate cancer treatment. Strengthening pelvic muscles prior to surgery has been shown to reduce post-op incontinence (Chung etal 2017).

♀Females - About 1 in 3 women experience SUI at some point in their lives (SUI-Patient-Guide, 2020).

Pathophysiology:

• Etiology may be childbirth, low estrogen, obesity, recent urinary catheterization, or surgery.
• Urethral hypermobility due to anatomical changes such as weakened pelvic floor muscles, or defects such as fascial detachments.
• Intrinsic sphincter deficiency (ISD) is due to a weakening of the muscle of the urethral sphincter.

Signs and Signs:

Mild SUI - A small amount of urine lost during rigorous physical activities including: sports or exercising, sneezing, laughing, coughing, or lifting.

Moderate to severe SUI - larger volumes of urine loss or incontinence that occur with low impact movements such as standing up, walking, or bending over.

• Self-care
  

  ♂♀	Urinate more often to reduce the amount of urine that leaks
  ♂♀	Avoid constipation and straining at stool
  ♂♀	Avoid bladder irritants: caffeine, tobacco, alcohol, spicy food, citrus, carbonated drinks
  ♂♀	Pelvic muscle exercise
  ♂♀	Biofeedback
  ♀	Vaginal weight training with cones
  ♀	Pelvic floor electrical stimulation
  ♂♀	Bladder training, usually scheduled voiding.

• Medical
  

  ♀	Estrogen cream remains controversial regarding its efficacy.
  ♀	Pessaries are available in many forms and sizes. Properly fit, they are a safe and effective option but must be fit by trial and error.
  ♂♀	Duloxetine - works like an SSRI but also blocks re-uptake of Noradrenaline. Off label use in patients who do not want or are unsuitable for surgery and ♂ post prostate surgery.
  ♂♀	Nerve stimulators. There are two types of devices that use painless electrical pulses to stimulate the nerves involved in bladder control (sacral nerves). One type is implanted under your skin in your buttock and connected to wires on the lower back. The other type is a removable plug that is inserted into the vagina. Stimulating the sacral nerves can control overactive bladder and urge incontinence if other therapies haven't worked. ( Mayo Clinic, 2021)

• Surgical
  

  ♂♀	Intramural Bulking Injection - Collagen, silicone or another material is injectied into urethral wall just distal to the bladder neck. Bulking injection is not as successful as sling procedures; repeat injections may be required over time.
  ♀	Burch Colposuspension restores the urethra and vagina to functional positions by elevating the bladder neck and stitching the periurethral tissue to the to Cooper's ligaments.
  ♂♀	Marshall-Marchetti-Krantz urethropexy elevates the urethra and bladder neck by stitching the periurethral tissue to the pubic periosteum.
  ♂♀	Sling Procedures - Trans Obturator (TOT), Suburethral (SUT) and Tension free Vaginal (TVT). Slings can be inserted to support a prolapsed urethra and return the external urethral sphincter to full function. The slings are either the autologous fascia grafts or           synthetic fibres. Risk of post-operative obstruction can be significant.
  ♂♀	Artificial Urinary Sphincter Insertion - An inflatable fluid-filled occlusion cuff is implanted around the ♀ bladder neck. The cuff is connected to a small manually operated valve/pump assembly placed in one of the labia and to a pressurized fluid-filled elastic reservoir in the abdominal wall. Squeezing the pump moves fluid from the cuff, opens the urethra, and expands the reservoir. Pressing the valve allows fluid under pressure in the reservoir to inflate the cuff. A similar (cuff/pump/reservoir) apparatus is placed around the urethra, distal to the pelvic floor muscles in male patients.

Instant Feedback:

Artificial urinary sphincter in women. Cambridge University Hospitals, National Health Service Foundation Trust (2020). Document 33981.
From: https://www.cuh.nhs.uk/patient-information/artificial-urinary-sphincter-in-women/

Pessaries (2021) Madhero88, CC BY-SA 3.0. https://upload.wikimedia.org/wikipedia/commons/b/bf/Pessary.png