Stress incontinence of varying degrees is frequent in women, especially those who’ve given birth to multiple children. The workup includes a careful history: urinary loss upon cough or laughing suggests stress incontinence, while continuous leakage indicates overflow incontinence. If you suspect the latter, review the precipitants such as caffeine, diuretics and alcohol. You also need to exclude urinary retention (portable scanners that measure the post void residual are now readily available). For a full assessment, consider a digital rectal as well as a pelvic exam.

Marshall test

A positive Marshall test is indicative of stress incontinence: ask the patient to cough with a full bladder, and there should be a gush of water. With one or two fingers supporting the urethra upwards, towards the pubis, there should be no loss of urine on coughing.

In cases where the woman needs several pads per day to stay dry, a cystoscopic evaluation can rule out conditions more often associated with urgency incontinence, such as infections, stones, interstitial cystitis and carcinoma-in-situ. With pure stress incontinence, the bladder should be normal.

Treatment

Vigorous pelvic muscle (Kegel) exercises are usually the first line of treatment. They involve training the muscle normally used to stop urine in mid-flow. The key is to do the exercises with dedication, and if there’s no improvement, a consultation with a physiotherapist can help. Nurse practitioners and continence clinics are also a great resource for teaching Kegel exercises. Restricting daily fluid intake to 1-1.5 litres per day and minimizing caffeinated beverages and alcohol intake is another option. In Europe, duloxetine, an SNRI, is licensed for the treatment of stress incontinence, but in Canada this indication is off-label.

Surgery

For significant symptoms, bladder suspension surgery is traditionally performed. These operations are still done and have a good success rate (although the majority of women are again incontinent 10 years later), but sling procedures are now overtaking all others in popularity.