Introduction

Urinary incontinence is a common symptom that can affect women of all ages, with a
wide range of severity and nature. While rarely life-threatening, incontinence may seriously
influence the physical, psychological and social wellbeing of affected individuals. The impact
on the families and carers of women with UI may be profound, and the resource implications
for the health service considerable. Stress urinary incontinence (SUI) is the most common
presentation. For most symptomatic women, quality of life is impaired, as SUI causes
significant personal and financial burden. We can expect to see ever-increasing numbers of
women as our Canadian population ages and as the prevalence of established risk factors for
incontinence in women increase, including obesity, diabetes, and smoking. As the providers
of care for these incontinent women, we are obliged to continue to search for the most effective
and durable treatment options and ensure that what is offered is safe.

Deffinition

Stress urinary incontinence (SUI) is the complaint of involuntary leakage on effort or exertion
or on sneezing or coughing. During effort or exertion, the intra-abdominal pressure is raised,
and the urethral sphincter is unable to maintain a pressure higher than that exerted on the
bladder. Subsequently, urine leakage occurs during everyday activities such as lifting,
laughing, jumping, sneezing, or coughing2
Classification

Prevelance of Disease

Urinary incontinence affects 17-45% of women worldwide and stress urinary

incontinence is responsible for 48% of all cases. Stress urinary incontinence (SUI) is the most
common subset of urinary incontinence affecting women (Elmissiry, Mahdy & Ghoniem
2011). Globally, literature estimates 200 million women live with incontinence (Norton &
Brubaker 2006). However, the prevalence may be higher as many females with SUI do not
seek help for fear of embarrassment (Luber 2004). Stress urinary incontinence as defined by
Haylen et al. (2010:5) is a ‘complaint of involuntary loss of urine on effort or physical exertion
(e.g. sporting activities), or on sneezing or coughing’. Physiologically it occurs as a result of a
sudden increase in intra-abdominal force resulting in the bladder pressure exceeding the
urethral pressure (Norton & Brubaker 2006).
Factors that predispose women to SUI, such as ageing, smoking and obesity, have been
highlighted in literature (Luber 2004). In terms of pregnancy and childbirth there has been
conflicting evidence and the influence of these factors is not well understood (Luber 2004).
However, a study by Lukacz et al. (2006) revealed that women who delivered vaginally had a
higher risk for pelvic floor disorders, which is independent of parity. Furthermore, women who
sustain anatomical or neuromuscular changes following childbirth may remain asymptomatic
as a result of compensatory mechanisms (Bump & Norton 1998) and only display signs of SUI
later on because of muscle loss as a result of ageing or injury (Norton & Brubaker 2006). The
management of SUI does vary but conservative management should initially be considered
(National Institute for Health Clinical Excellence [NICE] 2013).

Pathophysiology of SUI

The main anatomic hypotheses for development of SUI are as follows:

1) the loss of structural support,

2) the hammock, and

3) the neural hypotheses

1. Loss of structural support hypotheses: Supportive structures to the bladder neck and
urethra are necessary to maintain urethral closure pressure. Intact attachments of the
suburethral fascia to the fascia of the arcus tendineus and the LA construct a firm shelf
that remains stable when faced with increased forces generated by a cough or sneeze14)
. Disruption of this shelf, such as weakness of the LA or damage to fascial attachments,
as described in the loss of structural support hypotheses, could result in SUI. Aging and
childbirth injury are considered the main etiological factors for LA weakness14) .
2. The hammock hypotheses: In this hypothesis, the position of the urethra remains
constant, but the compression of the pelvic floor muscles and fascia, which support the
urethra, is decreased14) . In a normal support system, intra-abdominal pressure pushes
the urethra against the hammocklike supportive layer, and the urethral lumen closes,
which in turn does not allow urine to pass. However, in the case of an abnormal
 supportive layer, the lumen is not closed completely, thus resulting in urine leakage13,
14) .
3. The neural hypotheses: The main neural hypothesis for development of SUI is
associated with the pudendal nerve injury. The pudendal nerve innervates the external
urethral sphincter. So, any damage to the pudendal nerve (e.g., due to the recent vaginal
delivery) results in SUI3) . In addition to the above mentioned hypothesis concerning
UI, there are some risk factors that may result in the occurrence of SUI. These are as
follows: Childbirth15, 16) , Age17) , Decreased collagen content and elasticity18) ,
Race and ethnicity15–17) , Obesity17, 19) , Smoking, chronic cough, respiratory
diseases20) , Pelvic surgery17) , Chronic constipation20) , and Carbonated drinks19) .
Furthermore, there are also some nonspecific risk factors, such as pelvic organ
prolapse21) , medications22) , fluid intake23) , fecal incontinence24) , and pelvic
pain20) , that may result in SUI. It is worth mentioning that the coexisting pelvic
symptoms might be as follows: dual incontinence and pelvic organ prolapse,
constipation, sexual dysfunction, chronic pelvic pain, low back pain, and hip pain8)
Knowledge of the anatomy of the urinary support system facilitates
understanding about how continence is achieved. The system can be divided into two
parts: the bladder neck support system and the sphincter system.8 Support for the
urethra is maintained by the anterior vagina; the endopelvic fascia; the arcus tendineus
fascia of the pelvis; and the levator ani muscles, which are divided into three parts: the
puborectalis, iliococcygeus, and pubococcygeus muscles (Figure 1). These structures
provide a hammock-like support system for the urethra on the anterior wall of the
vagina. When the support tissues are stretched (eg, during childbirth) the urethra rotates
to a downward and backward facing position. Defects or alterations in this support
system contribute to the symptoms of SUI, as evidenced by leakage of bladder contents.
Possible risk factors for developing these defects include birthrelated injuries,
pregnancy, smoking, obesity, and aging.9 Defects that result in SUI can be repaired
surgically with techniques such as a retropubic colposuspension or pubovaginal sling
or via minimally invasive RF bladder neck suspension.

Diagnosis
Disease management

Case Study

Reference