Stephan L. Werner, M.D., F.A.C.S.

Stress Incontinence is the most frequent type of incontinence in females.  It is leakage of a varying amount of urine associated with laughing, coughing, straining, running, etc.   It may be minimal, a drop or two on a rare occasion, moderate, requiring changing underwear two or three times a day, or wearing a minipad, or severe, requiring several large pads a day.  It is frequently ignored because: it is mild, "it happens as women age", "there is nothing that can be done about it", or it is too embarrassing to talk about. The vast majority of patients can be cured.

Causes  The female urinary system sits in a precarious position, just in front of the vagina.  As a result, it has poor support, only the vaginal wall, (see Fig 1).   In addition it is subjected to repeated trauma as a result of sex, births, and weakening of the tissues as women go through menopause and lose the strength imparted to the pelvic tissues by female hormones.  As a result, the bladder and urethra "fall",   leading to shortening and widening of the urethra, (see Fig 2).

                                 Fig. 1                                               Fig. 2

Although the mechanism of continence or control of urine is very complex,  the major component can easily be visualized as an old fashioned "finger trap", made of muscle, rather than straw, (Fig 3).  In the normal anatomy, the urethra is fixed at both ends, so when the muscles contract, the urethra narrows, (Fig 4), shutting off flow of urine.  When the bladder has "fallen"  the upper end of the urethra is no longer fixed, so when the muscles contract, the urethra becomes shorter and wider, allowing urine to leak, (Fig 5) especially with coughing or other forms of straining.

                                                          Fig. 3                                      Fig. 4                                     Fig. 5   

    A second, more minor component to urinary control is the voluntary sphincter or valve muscles of the pelvic floor.  These surround the urethra. vagina and rectum, and are the muscles used to "hold back" urine on a voluntary basis.

    Sometimes, the bladder has unusually high pressures due to nerve or bladder muscle dysfunction.  In this situation, what is an adequate valve mechanism may be overpowered.

    The treatment of stress incontinence is based on evaluating and treating these factors.

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