Stress Urinary Incontinence (SUI)

How stress incontinence happens

When you cough or lift, pressure inside the abdomen pushes down on the bladder. Normally, the pelvic floor muscles and supportive tissues hold the urethra in place and squeeze it shut, keeping urine in. In stress incontinence:

• the urethra is poorly supported and moves downward (urethral hypermobility), or
• the urethral sphincter muscle is weak (intrinsic sphincter deficiency)

So leakage occurs with each pressure spike, without an urge to urinate. This differs from overactive bladder and urge incontinence, where leakage follows a sudden strong urge. Many people have both, called mixed incontinence.

Causes and risk factors

In women

• pregnancy and vaginal childbirth, especially large babies, forceps delivery or long labors
• menopause: lower estrogen weakens urethral tissues
• aging
• obesity: extra abdominal pressure
• chronic cough from smoking, asthma or COPD
• chronic constipation and straining
• high-impact exercise and heavy lifting
• pelvic organ prolapse
• previous pelvic surgery

In men

• prostate surgery, especially radical prostatectomy for cancer
• less often, pelvic radiation or nerve injury

Symptoms

• leakage of small amounts of urine with coughing, sneezing, laughing, lifting, standing up or exercise
• larger leaks with more severe weakness
• usually no urgency before leaking
• leakage during sex in some women

Diagnosis

• history, including leakage triggers, childbirth, medicines and fluid habits
• bladder diary for 3 days
• pelvic exam to look for prolapse and assess pelvic floor strength
• cough stress test: coughing with a full bladder to see leakage
• urinalysis to rule out infection or blood
• post-void residual bladder scan
• urodynamic testing before surgery in complex cases or when the diagnosis is unclear

Treatment

Pelvic floor muscle training (Kegel exercises)

The first-line treatment, effective for most women when done correctly and consistently.

1. Identify the muscles: imagine stopping the flow of urine or holding in gas. Do not tighten your buttocks, thighs or belly.
2. Squeeze and hold for up to 10 seconds, then relax for 10 seconds.
3. Do 10 to 15 repetitions, 3 times a day, plus quick squeezes.
4. Use "the knack": squeeze just before and during a cough or sneeze.
5. Continue for at least 3 months to see results, then keep going to maintain them.

A pelvic floor physical therapist can teach correct technique, sometimes using biofeedback or electrical stimulation. Apps and vaginal weights may help.

Lifestyle

• weight loss if overweight: even 5 to 10% helps
• treat constipation and chronic cough, and stop smoking
• avoid excessive fluid, but do not restrict to the point of dehydration
• limit caffeine and alcohol if they worsen symptoms

Devices

• vaginal pessaries: a silicone device inserted into the vagina to support the urethra
• over-the-counter vaginal inserts designed for incontinence
• urethral inserts, used before exercise

Vaginal estrogen

May help postmenopausal women as part of treatment, particularly with other urinary symptoms.

Surgery

For women whose symptoms persist despite conservative treatment:

• midurethral sling: a narrow strip of synthetic mesh placed under the urethra through a small vaginal incision. It is the most studied and widely used surgery, with high success rates. Risks include mesh exposure, pain and difficulty urinating
• autologous fascial sling: using tissue from your own body
• Burch colposuspension: stitches lifting tissues near the bladder neck
• urethral bulking injections: a less invasive option with lower and shorter-lasting success

For men after prostate surgery: male slings or an artificial urinary sphincter.

There is no FDA-approved medicine for stress incontinence in the US.

Outlook

Most people improve significantly with pelvic floor training and lifestyle changes. Surgery is effective for those who need it, with many remaining dry for years. Stress incontinence is common but not a normal part of aging that must be tolerated.

Frequently asked questions

What is stress incontinence?

Stress incontinence is leakage of urine when pressure on the bladder rises, such as when you cough, sneeze, laugh, lift or exercise. It is caused by weakened pelvic floor muscles and tissues that normally keep the urethra closed.

Do Kegel exercises really work for stress incontinence?

Yes. Supervised pelvic floor muscle training cures or improves stress incontinence in most women who do it correctly for at least 3 months. A pelvic floor physical therapist can make sure you are using the right muscles.

What is the difference between stress and urge incontinence?

Stress incontinence is leakage with physical pressure like coughing or exercise, without warning. Urge incontinence is leakage after a sudden, strong urge to urinate, often from overactive bladder. Many people have both.

Can stress incontinence be cured?

Often yes. Pelvic floor training cures many mild to moderate cases. Sling surgery has high success rates for persistent symptoms. Weight loss, treating constipation and stopping smoking also help.

Is stress incontinence normal after having a baby?

It is common in the months after childbirth, but it is not something you have to live with. Pelvic floor exercises often help it resolve. If leakage persists beyond 3 months after birth, see your doctor or a pelvic floor physical therapist.