Stress Incontinence: Treatment, Triggers, Exercises

Stress incontinence is a type of urinary incontinence in which a small amount of urine (“pee”) leaks out whenever you cough, laugh, sneeze, or do any physical activity that exerts pressure on the bladder.

Fortunately, you can do things to help manage this common but aggravating condition, including making changes in diet, performing certain exercises, losing weight, and wearing bladder control pads. Severe cases may require specialist treatment, including a type of surgery called a sling procedure.

This article describes the causes and risk factors for stress incontinence, including how the condition can be managed with lifestyle changes, medications, and surgery.

Stress Incontinence Triggers

Stress incontinence is not caused by emotional stress. It occurs with weakening of the muscles that support the urethra (the tube through which urine exits the body).

This includes the urethral sphincters, a pair of muscular valves that regulate urine flow from the bladder to the urethra.

It also involves the pelvic floor muscles situated between the genitals and anus that you voluntarily squeeze to slow or stop peeing.

If these muscles weaken, any external pressure on the abdomen can squeeze urine out of the bladder, causing dribbling and leakage.

Physical activities that cause stress incontinence include:

• Bending
• Coughing
• Exercising
• Jumping
• Laughing
• Lifting heavy objects
• Running
• Sex
• Sneezing

Risk Factors

Studies suggest that between 15% and 35% of adults experience urinary incontinence. Stress incontinence, the most common type, affects females at a rate three times greater than that of males.

Certain factors can increase the risk of stress incontinence. These include conditions that exert pressure on the bladder and others that damage the nerves that control the urethral sphincters.

Risk factors for stress incontinence include

Risk factors specific to females include:

Risk factors specific to males include:

Why Stress Is Only One Part of Incontinence

It is not uncommon for stress incontinence to co-occur with other forms of incontinence, such as urge incontinence. Urge incontinence is when you have the sudden, uncontrollable urge to pee before the loss of bladder control.

This co-occurrence, known as mixed incontinence, affects nearly 1 in 3 people with incontinence. Mixed incontinence is harder to treat, and it has a higher risk of recurrence than stress incontinence alone (41% vs. 31%, respectively).

This is why it is important to get an accurate diagnosis from a specialist called a urologist or obstetrician-gynecologist (ob-gyn) to ensure that the right treatments are dispensed.

Other forms of incontinence include overflow incontinence (in which the bladder overfills and leaks without the urge to pee) and functional incontinence (in which physical or mental limitations affect your ability to get to the bathroom on time).

Exercises to Train Stress Incontinence Muscles 

One of the best ways to treat stress incontinence is with exercises that strengthen the pelvic floor muscles. Doing so can help prevent dribbling even if the urethral sphincters are weak.

Kegel exercises, first described by American gynecologist Arnold Kegel in the 1940s, are central to strengthening the pelvic floor muscles. The exercise generally consists of three sets of eight to 12 contractions held for eight to 10 seconds, performed three times daily.

Other exercises that target the pelvic floor muscles can also be added.

Kegel Exercises

Kegel exercises can be done by people of any sex, but they need to be performed correctly to target the right muscles. You can do them in any position, although some people find it easiest to lie down when first starting.

To do Kegel exercises:

1. Focus on finding the muscles you use to urinate.
2. Tighten those muscles as much as you can.
3. Hold this position for eight to 10 seconds.
4. Rest for several seconds, then repeat for a total of eight to 12 repetitions.

Squats

Squats are excellent because they engage your core muscles and the muscles around your pelvis. Keep your buttocks and pelvic floor muscles tight throughout the movements for the best results.

To do squats:

1. Stand with your feet hip-width apart and your knees aligned with your toes.
2. Bend your knees slowly while moving your buttocks toward the floor. Lean forward slightly with your back straight.
3. Return to standing position, keeping your buttocks and pelvic floor muscles tight.
4. Rest for a few seconds, then repeat for eight to 12 repetitions.

Bridges

Bridges are a type of floor exercise that can strengthen your gluteus (buttock) muscles in addition to your pelvic floor muscles and lower back.

To do the bridge:

1. Lie on your back with your knees bent, feet flat on the floor, and arms at your sides.
2. Tighten your buttocks and pelvic muscles, and then lift your buttocks as far off the floor as you can without straining.
3. Hold this position for eight to 12 seconds.
4. Relax your muscles and lower your buttocks back down to the ground with control.
5. Rest for a few seconds, then repeat for eight to 12 repetitions.

Dietary and Lifestyle Interventions With Weak Bladder

Certain dietary and lifestyle changes can help reduce the severity and frequency of stress incontinence. Key to this is the management of fluids, losing excess weight, eating the correct diet, and quitting cigarettes.

Fluid Management

Incontinence is more likely when your bladder is full. While it is important to stay well hydrated, you can avoid bladder leakage by taking regular sips of water throughout the day rather than drinking large amounts all at once.

You should also limit the intake of alcohol, which has a diuretic effect (meaning that it promotes urination). Caffeine in coffee, black tea, and colas has the same effects and can also trigger bladder contractions. Fizzy drinks may be problematic if you have mixed incontinence.

It’s important never to deprive yourself of fluids as this can lead to constipation. Chronic constipation and straining can weaken the pelvic muscles and make stress incontinence worse.

Weight Loss

Obesity contributes to stress incontinence in two ways. First, the added weight weakens pelvic floor muscles. Second, it increases visceral fat surrounding abdominal organs, making it easier to compress the bladder when bending, moving, or engaging in physical activities.

Weight loss, combined with pelvic floor exercises, can help reverse these issues. Work with a healthcare provider to design a sustainable program involving routine exercise and a nutrient-rich, low-saturated fat diet.

Studies have also shown that moderate physical activity decreases the risk of urinary incontinence in middle‐aged and older women. Almost any type of exercise can help strengthen pelvic floor muscles, including swimming, walking, and cycling. Try to exercise on most days of the week.

Diet

Although there is no such thing as an incontinence diet, studies have shown that stress incontinence is strongly linked to a high consumption of saturated fat. Saturated fats are those derived from animals, including meat and dairy products.

Along with avoiding alcohol and caffeine, cutting back on fatty red meat, full-fat dairy, and processed food rich in saturated and trans fat can be an important part of the treatment plan.

A Mediterranean diet rich in fruits, vegetables, fish, and extra-virgin olive oil may also be effective for people with mixed incontinence.

Stopping Smoking

Smoking is well known to contribute to urge incontinence by irritating the bladder, but there is also evidence that it can indirectly promote stress incontinence as well. This is because heavy smoking is linked to a chronic cough, which, in turn, places stress on the pelvic floor muscles that can weaken them over time.

Quitting cigarettes can be tough, but smoking cessation aids can help, Many of these aids are fully covered by insurance under the Affordable Care Act. Speak with a healthcare provider.

When Symptoms Warrant Specialist Procedures and Surgery 

When lifestyle changes and exercise fail to control bladder leakage, prescription medications and specialist procedures may be recommended. These include surgeries typically reserved for more severe cases.

Medications

In the United States, no medications are specifically approved for the treatment of stress incontinence.

With that said, some healthcare providers may prescribe a drug called Cymbalta (duloxetine) as an alternative to surgery for women with severe stress incontinence. The drug, approved for such use by the European Medicines Agency, has been shown to cut the frequency of stress incontinence episodes in women.

Even so, some experts suggest that the risks of treatment may outweigh the benefits. Among other concerns, studies suggest that Cymbalta may increase the risk of suicidal behaviors in women with stress incontinence.

Specialist Procedures

Several minimally invasive procedures can be used to treat moderate to severe cases of stress incontinence. Some have proven highly effective and may help you avoid more invasive procedures like surgery.

Some of these options include:

• Incontinence devices: These include a flexible silicone device called a vaginal pessary that is worn in the vagina to reduce bladder leakage. There are also over-the-counter, tampon-like devices called urethral inserts (sold under the brand name Poise Impressa and others) that are inserted into the urethra before physical activities, such as sports.
• Urethral bulking agents: These are soft, water-based gels that are injected into the tissues around the urethra sphincter. Products like Bulkamid (injectable hydrophilic gel) help reduce stress incontinence by restoring the natural closing of the sphincter.
• Electrical nerve stimulation (ENS): These are non-implanted devices that deliver a mild electric current to the nerves in the pelvis or lower back involved in urination. A 2017 review of studies concluded that there was “moderate” evidence supporting the use of ENS in treating stress incontinence. Home units with vaginal or anal electrodes are available.

Surgeries

When conservative treatments fail to provide relief, surgery may be a reasonable option. Four types are commonly used for people with stress incontinence:

• Midurethral sling procedure: This is the most common surgical option in which a small piece of mesh is placed under the urethra at the base of the bladder to lift it like a hammock. This prevents it from dropping whenever laughing, coughing, or engaging in similar activities.
• Traditional sling procedure: This involves the creation of a sling using a strip of tissues harvested from your lower abdomen or thigh. The ends of the sling are attached to each side of the pubic bone and threaded under the urethra to lift it.
• Retropubic colposuspension: This surgical procedure lifts the urethra and bladder neck using a series of stitches that pull together ligaments at each side of the pubic bone. The stitches hoist the passages so that they are less prone to leakage.
• Inflatable urethral sphincter: This is an implanted device used in males that replicates the action of the urethral sphincter. A flexible cuff is implanted at the neck of the bladder and inflated with a hand pump implanted in the scrotum. The cuff can be deflated with a release valve.

The risks of surgery for stress incontinence include postoperative infection, urinary tract infections, difficulty urinating, and injury to nerves or blood vessels of the bladder.

Some people may also have continued incontinence, while others may experience new incontinence (including a nerve-related form of incontinence called neurogenic bladder).

Short- and Long-Term Stress Incontinence Effects 

Stress incontinence can take an emotional toll on your life, causing discomfort or anxiety that can lead to social isolation, depression, and a reduced quality of life. Some studies have shown that stress incontinence can directly interfere with work productivity and influence key career decisions, such as whether to start a new job.

Stress incontinence can also impact sexual relationships, particularly among women. This can contribute to a reduction in the frequency of sex or lead to the complete avoidance of sex. This appears to be irrespective of how long or recently the condition occurred.

Stress incontinence can also affect physical health. Exposure to urine can cause skin irritation, and repeated and ongoing exposure can damage tissues by changing the skin’s pH balance (acidity and alkalinity). This can make the skin more permeable and vulnerable to infection.

Possible complications of stress incontinence include:

• Chronic or recurrent urinary tract infections (UTI): Caused when a local infection spreads into the urethra
• Intertrigo: A superficial inflammatory skin condition of skinfolds, such as the vulva or foreskin
• Incontinence-associated dermatitis (IAD): A reactive immune response that causes skin redness, swelling, itching, and the formation of tiny blisters on the genitals
• Secondary skin infection: The spread of a local skin infection into deeper tissues, leading to pain, swelling, skin discoloration, fever, blisters, and pus

Tips to Make Living With Stress Incontinence Easier 

There are ways to cope and live well while finding an effective treatment for stress incontinence. Planning is key.

In addition to Kegel exercises and changes in diet, people living with stress incontinence will often recommend the following to reduce anxiety and stress:

• Choose the right protective products: An incontinence pad may provide ample protection if you have light bladder leakage. For heavier leakage or long outings, disposable incontinence underwear or washable, leak-proof undergarments like Knix may be a better option.
• Keep an extra supply: When heading to work or social events, bring extra incontinence pads or protective underwear and a change of clothes. Incontinence pads fit snugly in larger handbags and satchels.
• Change out of wet clothes: Remove wet pads or clothing immediately to avoid skin irritation. Clean with gentle soap and water. Always have disposable unscented wipes in your car, office desk, or purse in case of an accident.
• Plan your bathroom breaks: Before going out, use Google Maps or Apple Maps to find your nearest bathrooms. Choose an aisle seat nearest the bathroom when on airplanes or in movie theaters or auditoriums.
• Empty your bladder strategically: Doing so before an event, outing, or sex reduces the chance of bladder leakage. You can further reduce the risk by stopping fluids an hour beforehand.
• Grab a pillow: If you feel a sneeze or cough coming on, tighten your abdominal muscles and hold a cushion or pillow to your belly. This limits the contraction of the abdomen.
• Tell a friend: Talking openly with a sex partner or friend removes some of the stress and stigma associated with incontinence. Remember that incontinence is a common condition affecting millions of people. By opening up, you may find that others are dealing with the same situation as you.

Summary

Stress incontinence is caused when a physical activity like laughing, sneezing, or lifting heavy objects causes you to leak a little urine. Females are more vulnerable to stress incontinence, as are people who smoke, have obesity or diabetes, or have conditions that cause chronic coughing.

Stress incontinence can often be effectively managed with Kegel exercises, fluid management, weight loss, changes in diet, and smoking cessation. If needed, medications like Cymbalta, devices like vaginal pessaries, or specialist treatments like urethral bulking can be used. Severe cases may benefit from surgery, most commonly a midurethral sling procedure.