Mid-Urethral Sling

Stress Urinary Incontinence (SUI) is when urine leaks out with sudden pressure on the bladder and urethra, causing the sphincter muscles to open briefly. With mild SUI, pressure may be from sudden forceful activities, like exercise, sneezing, laughing or coughing. If your SUI is more severe, you may also leak with less forceful activities like standing up, walking or bending over. Urinary “accidents” like this can range from a few drops of urine to enough to soak through your clothes. 

SUI is a very common bladder problem for women. It happens less often in men.

Another common bladder problem is called Overactive Bladder (OAB), or Urgency Urinary Incontinence (UUI). People with OAB have an urgent, “gotta go” feeling that they can’t control. Some people with OAB leak urine when they feel that urge. The difference between SUI and OAB is anatomical. SUI is a urethral problem while OAB is a bladder problem. With SUI, the urethra cannot stop the sudden increase in pressure. With OAB, the bladder spasms and squeezes uncontrollably. To learn more about OAB, visit our OAB web page.

Many people with SUI also have OAB. When both types of urinary incontinence are happening, it is called “Mixed Incontinence.”

Key SUI Statistics

About 1 in 3 women suffer from SUI at some point in their lives. Urinary incontinence increases with age. Over half of women with SUI also have OAB.

• About one-third (1 out of 3) of women age 60 find that they sometimes leak urine. 
• About half (1 out of 2) of women age 65 and above find that they sometimes leak urine.

Men with urine leakage have overactive bladder (OAB) more often than SUI. For men who have SUI, it is likely due to prostate cancer surgery, pelvic nerve injury or damage.

What Happens Normally?

The urinary tract includes two kidneys, two ureters, a bladder, aurethra and a sphincter. The bladder is secured in place by fascia in the pelvic floor. This system works together to store and remove waste, specifically urine, from our bodies.

• The kidneys make urine. The kidneys clean our blood and remove waste and excess water (urine). They also serve as our body’s filter to control electrolytes, fluid balance, pH and blood pressure. Urine drains down through thin tubes called ureters into the bladder.
• The ureters move urine from the kidneys to the bladder. 
• The bladder is a balloon-like organ. It stores urine. The bladder muscles contract (squeeze) when we’re ready to release urine.
• The urethra is a tube at the bottom of the bladder where urine exits the body. It has sphincter muscles to keep the urethra closed and prevent urine from leaking out, until you’re ready to release urine. The sphincter muscle relaxes when the bladder contracts and urination occurs. 
• The pelvic floor includes a sling (like a hammock) of muscles and fascia that supports the bladder, rectum and uterus. 

Symptoms

The key symptom of SUI is when urine leaks out during any activity that increases abdominal pressure. The amount can be a few drops to tablespoons or more. If you have mild SUI, you will leak during forceful activities such as exercise. You may also leak when you sneeze, laugh, cough or lift something heavy. If your SUI is moderate or more severe, you may also leak when you do less strenuous activities, like standing up or bending over.

These symptoms are different from urge incontinence or overactive bladder (OAB). With OAB, you feel an urgent and uncontrollable need to urinate. This “urgent” feeling could happen quite often. Leaks may involve a large amount of urine. 

How Can SUI Affect my Life?

Many people find that SUI gets in the way of daily and social activities. It can affect family and sexual relationships. Some people even begin to feel isolated and hopeless because of it.

You may be embarrassed about this problem. You may not want to talk about it with a loved one or even a doctor. Please know that your primary care practitioner or a specialist can help.

Ask yourself whether leaking urine or the fear of leaking urine has:

• Stopped you from doing things outside of your home?
• Caused you to be afraid to be too far from a bathroom or a change of clothes?
• Stopped you from exercising or playing sports?
• Changed the way you live because you’re afraid of leaks?
• Made you uncomfortable with yourself and your body?
• Changed your relationships with friends or family?
• Made you avoid sex because you are worried that you will leak urine and be embarrassed?

If you answer yes to some of these questions, you should know that things can change for the better. There are many ways to manage and treat SUI.

Causes

The pelvic floor supports the bladder and urethra. If this area gets stretched, weakened or damaged, then SUI can happen. Pregnancy and childbirth can cause this. Chronic coughing or nerve injuries to the lower back or pelvic surgery (like surgery for prostate cancer) can also weaken the muscles.

What increases my risk of getting SUI?

SUI impacts older women most often, however, it is not caused simply by aging or by being female. It happens in younger women and some men too. For some young women, it can result from childbirth, and then improve after time. 

Risk factors for SUI include:

• Gender: females are more likely to get SUI
• Pregnancy and childbirth
• Being overweight
• Smoking
• Chronic coughing
• Nerve injuries to the lower back
• Pelvic or prostate surgery

Diagnosis

How do I talk about SUI with my Healthcare Provider?

The first step in diagnosing SUI is to talk to your healthcare provider about your symptoms. If you think you have SUI, tell your provider about what’s happening. That is the only way to know for sure and find relief. Start with a Primary Care provider who can often initiate treatment without sending you to a specialist. If needed, they can refer you to a urologist or gynecologist. These are doctors who have more experience with pelvic floor conditions like urinary incontinence. Some may have obtained additional certification in female pelvic medicine and reconstructive surgery (FPMRS).

If you don’t feel comfortable talking about your symptoms, a little planning will make you more confident. Here are some tips to help begin a conversation with your provider to get help:

Be Prepared

Before your visit write down your experiences and questions and bring this with you. Your notes will help you remember what you want to say. Make lists of:

• Your symptoms, how they affect you, and how often
• Prescription drugs, over-the-counter-medicines, vitamins and/or herbs you take
• Past and current illnesses, surgeries or injuries
• Questions you want to ask

Bring up the Topic

If your healthcare provider doesn’t ask you about SUI symptoms, bring up the topic. Don’t wait until the end of your visit. Talk about it early on. That way there will be time for questions. If a nurse meets with you first, tell the nurse about your symptoms.

Speak Freely and Ask Questions

Tell your healthcare provider about your symptoms and feelings. Talk about how your life is affected. Your provider is used to hearing about all kinds of problems. It’s okay to talk freely.

Some people find it helpful to use questions like these to help begin the conversation:

• I am afraid to be too far from a bathroom or change of clothes because of leaking. What can I do to manage this problem better?
• I’ve changed my daily habits because I am afraid of “accidents”. What can I do to get my life back?
• I have stopped exercising or playing sports because I leak urine. Can you help me get back to doing the things I enjoy?
• I have become uncomfortable with myself and my body because I leak urine. What can I do to regain control? 
• I avoid having sex because I am worried that I may leak. Please help me learn some strategies to help with this.

Talk About Next Steps

When you speak with someone who can address your concerns, it helps to write down what you want to ask in advance. Bring your list with you to your visit. You may also want to begin a bladder diary. The bladder diary is a tool to track urinary patterns. With it, you write down when you urinate and leak, what might trigger problems, and eating /drinking patterns for a few days. Bring the diary with you to your appointment. You and your healthcare provider will go over it together.

Next, your healthcare provider will begin an evaluation to learn what’s causing the problem. Below are some things healthcare providers may do to find the cause of SUI:

Your Medical History

Your healthcare provider will ask about your symptoms, how long you’ve had them, and how they’re affecting you. A medical history will include questions about:

• Your past and present health 
• The frequency, timing and severity of your symptoms
• Pain or other symptoms (like bloating or constipation)
• Your diet
• How much and what kinds of liquids you drink daily
• For women: your menopausal status and childbirth history Delete bullet
• Your past surgeries (especially if you had pelvic surgeries)
• Over-the-counter and prescription drugs you usually take

Your healthcare provider is there to help you, don’t be embarrassed talking about this topic. Speak honestly. This information will guide the best way to treat your problem.

The Physical Exam

For women, your physical exam may include checking your abdomen, the organs in your pelvis, and your rectum. For men, a physical exam may include checking your genitalia and abdomen, prostate and rectum. Your healthcare provider may also test how strong your pelvic floor muscles and sphincter muscles are. You may be asked to squeeze your pelvic muscles and sphincter muscles for a Kegel test.

The physician may have you perform maneuvers such as coughing, straining down or stepping to see if these actions cause you to leak urine.

Bladder Diary

It is a good idea to start and keep a “bladder diary.” This is a tool to track your day-to-day symptoms. In your diary, you will write down what fluids you drink and how often you go to the bathroom. You also need to note when you have leaks. Include what you were doing when the leak happened, such as running, coughing or sneezing.

The symptoms you share will help your provider understand what’s happening so he/she can begin to diagnose and provide treatment for you.

Pad Test

There are two types of urinary pad tests: the one- hour test and the 24-hour test. The one-hour pad test is usually done in the office to learn about leakage with exercise or movement. The pad is removed and weighed afterwards to evaluate the amount of urine leaked. The 24-hour urine pad test is usually done at home for a complete day and night’s evaluation. 

Other Testing

Sometimes the description of symptoms and physical exam do not provide enough information for an accurate diagnosis. When this is the case, you may be referred to a specialist for more comprehensive testing.

These specialized tests may be used for your diagnosis:

• A urinalysis or urine sample to test for a urinary tract infection or blood in the urine. 
• A bladder scan after urinating to show how much urine stays in your bladder after you urinate. 
• A Cystoscopy uses a narrow tube with a tiny camera to see into the bladder to rule out more serious problems.
• Urodynamic studies (UDS) are done to test how well the bladder, sphincters and urethra hold and release urine.

Once your provider understands the type of incontinence you have and rules out other conditions, he/she will offer you treatment options to feel better. 

Treatment

You and your healthcare provider can talk about ways to treat or manage your SUI symptoms. Your provider should explain the benefits and risks of each option to help you decide what will work best for you. Remember that not every treatment works for everyone, and you may have to try more than one to find relief.

SUI treatment options:

• Lifestyle Changes to Treat SUI
• Medical Devices to Manage SUI in Women
• Surgery to Treat SUI

There are currently no drugs approved in the U.S. to treat SUI. Sometimes if you have SUI and OAB (Mixed Incontinence), your health care provider may prescribe OAB drugs or OAB treatments. These drugs may help reduce leaks for an overactive bladder. They do not treat SUI.

What Lifestyle changes can treat SUI?

Absorbent Pads

You may need to rely on absorbent pads daily or from time to time. Pads are also used when waiting to have surgery or during recovery from surgery. Absorbent pads come in different sizes and styles. Some are simply an adhesive placed in your underwear, others are pull-on briefs. These may work for you, or you may decide that they don’t provide enough control.

For more information, on the absorbent products, visit our page on managing incontinence with products and devices.

Pelvic Floor Muscle Exercises (also called Kegel exercises)

Kegel exercises help strengthen your pelvic floor muscles. You perform Kegels by contracting (squeezing) and relaxing the pelvic floor muscles many times each day. Pelvic floor muscles help support the bladder and other organs. Exercising these muscles can make them stronger and help reduce or eliminate your SUI symptoms. To get the most benefit, do these exercises every day.

To make sure you perform these exercises correctly, your healthcare provider may refer you to a physical therapist. This therapist is someone who specializes in strengthening pelvic muscles. Visit our pelvic floor muscle exercises web article to learn more.

Maintain Good Bowel Function

Constipation can make incontinence worse. Try to prevent constipation. Eat high fiber foods (fruit, beans and dark-colored vegetables) to encourage regular bowel movements. It helps to drink 6 to 8 glasses of water each day, and exercise daily.

Maintaining a Healthy Weight

People who are overweight or obese are more likely to develop SUI. Losing weight reduces the severity of SUI. Many people find that losing just 10 pounds can lead to fewer leaks. Your healthcare provider can help you set safe, realistic goals for weight loss.

Bladder Training

A bladder diary is the starting point for bladder training. You record: (1) how much you drink; (2) when you urinate; and (3) when leaks occur. The diary allows you and your healthcare provider to see how often you urinate now and whether bladder training can help you. With bladder training, your healthcare provider may ask you to follow a fixed schedule to urinate. You may be asked to lengthen the time between bathroom visits by small amounts over time. It is important to try this only if your healthcare provider suggests it as some people have more urine leaks when they wait too long to go to the bathroom.

Quit Smoking

Quitting smoking is one of the most important things you can do for your health. A chronic cough from smoking may increase the frequency and severity of leaks. It may also cause added strain to the pelvic floor. When you quit smoking, coughing may decrease. This helps to reduce pressure on the pelvic floor muscles, which reduces leaks.

Devices to Control SUI in Women

Vaginal Devices for SUI

If your pelvic floor muscles are weak and you are female, an inserted vaginal device may prevent leaks. Examples are tampons, over-the-counter pessaries and custom fitted pessaries. These devices typically press against the wall of the vagina and the urethra. The pressure helps reposition and support the urethra. This leads to fewer leaks with minimal risk. There are different types of devices women can use which include:

• Vaginal Pessaries
  A vaginal pessary is a firm yet flexible device that is inserted into the vagina. It repositions and supports the urethra and/or uterus. 
• Disposable Pessaries
  A single use, disposable pessary was recently approved for use in the U.S. It is available over-the-counter without a prescription. You insert the device with an applicator, like a tampon. Once the pessary is in the vagina, the core and cover of the device support the urethra.
  Disposable devices are made to be used for a maximum of 8 hours in a 24-hour period. You remove it from the vagina using a pull string. It is thrown away after use. All pessaries have some risk of irritation or infection. If you notice this, let your healthcare provider know.
  Some women find that inserting a simple tampon during exercise prevents leaks. But tampons have not been approved for this purpose. There is no research that shows tampons can prevent urinary leakage.
• Non-Disposable Pessaries
  Prescription pessaries are small, often made of medical grade silicone. These must be fitted just for you by a specialist. Like other pessaries, they are inserted into your vagina. Your pelvic floor muscles hold it in place. When fitted properly, you won’t notice that it’s there. You can go about your daily activities comfortably. Your healthcare provider can remove, check and replace them. Or they can teach you how to remove, clean and replace them yourself.
  
  Some women wear the pessary 24 hours a day, but most women wear them during the day and remove them at night. The pessary must be removed before having sexual intercourse. It’s best not to wear them all the time, since they can irritate the urethra. This could lead to blood in the urine (hematuria) and urinary tract infections. Still, these devices are useful for reducing leaks during strenuous activities like running, lifting or playing tennis.
  
  Pessaries are generally safe, with a small risk of infection. If you use a pessary, set a schedule to visit with your healthcare provider. That way it can be checked, cleaned, and refitted on a regular basis or as needed.

Urethral Plug

To help prevent SUI during high activity, you may have the option of an occlusive device (also called urethral plug). These types of devices block the urethra, while a vaginal device adds support through the vagina.

A simple urethral plug can be inserted to create a barrier. They may be shaped like a thin flexible rod. Some have a balloon on the end that can be inflated and deflated to block leaks. When it’s time to urinate, they can be deflated or pulled out.

These plugs are used in rare and specific cases. Currently, there are no approved urethral plugs available in the U.S.

If you use any kind of vaginal device regularly to treat your SUI, your vaginal tissue may become irritated. Some devices should be thrown away after one use. Others need regular cleaning. If you use one of these devices, you should learn how to maintain good vaginal health. Also, be sure to set a schedule with your provider for regular check-ups and maintenance of these devices.

Devices to Control SUI in Men

Men may be offered a penile clamp/clip device to prevent SUI leaks. These external clamps may be used to restrict the flow of urine from the penis. Before buying this product, talk to your provider about the benefits or risks of using this device. Also, ask your healthcare provider about where you can buy this product.  

Surgery to Control SUI

Making the decision to have surgery can be very personal. It is made in consultation with your surgeon based on the characteristics of your incontinence, your goals and your preferences.

It helps to learn as much as you can before you decide to move forward with surgery. Explain your goals to your healthcare provider. Find out which type of surgery is recommended and how much it may reduce urine leaks to see if it’s worth doing. Learn what to expect during and after surgery. Also ask about risks and possible complications.

Here are a few sample questions for your healthcare provider to help you make the best decision:

• Which surgery is best for me? Why?
• What are the risks with surgery?
• Will surgery fix my SUI completely?
• How long is the recovery?
• Will I still have incontinence or other symptoms after surgery?
• Will my insurance pay for surgery?
• Should I do this now, or wait?

Waiting to have SUI surgery won’t harm you. Unlike some other medical conditions, delaying SUI surgery doesn’t usually change the outcome.

Surgery for SUI in women is usually very successful. While each of the most commonly performed surgeries are similar in terms of success rates, they have different risks. It is important to understand your options so you can feel confident about the decision you make. If you want to find out more about SUI surgery, ask your healthcare provider what kind may work best for you, why and for how long.

Below are different surgical procedures specific to men and women for SUI.

Urethral Injections for Women with SUI

Urethral Injections/Bulking Agents

Urethral injections are used to “bulk up” the urethral sphincter muscle that keeps the urethra closed. “Bulking agents” are injected into the urethra. This helps the sphincter to close the bladder better.

Often, the injections are done under local anesthesia in your healthcare provider’s office. The injections can be repeated if needed. This method may not be as effective as other surgeries, but the recovery time is short. Bulking agents are a temporary treatment for SUI. Of every 10 women who have these injections, between 1 in 3 are cured of leaks, which can last for a year.

Sling Surgery for Women with SUI

The most common surgery for SUI in women is “sling” surgery. In this surgery, a small strip of material (a sling) is placed under your urethra to prevent it from moving downward during activities. It acts as a hammock to support the urethra. Many sling techniques and materials have been developed. Slings can be made from your own tissue, donor tissue or surgical mesh.

For any type of sling surgery, there are different risks that should be discussed with your surgeon before starting. These are the primary sling surgeries used to treat SUI:

• Midurethral sling-The midurethral sling is the most common type of surgery used to correct SUI. The sling is made out of a narrow strip of synthetic mesh that is placed under the urethra with a variety of techniques: retropubic, transobturator and single-incision. Your doctor will recommend which anchoring location is right for you and review risks.
  • For sling surgery made from surgical mesh, the surgeon may only need to make a small cut (incision) in the vagina. The sling is then inserted under the urethra and anchored in the surrounding pelvic floor tissue. This surgery is short and recovery may be shorter than with an autologous sling. There are additional risks associated with using mesh that you should discuss with your surgeon.
    
• Autologous sling-In this type of surgery, the sling is made from a strip of your own tissue (autologous) taken from the lower abdomen or thigh. The ends of the sling are stitched in place through an incision in the abdomen.
  

To use your own body tissue for a sling, an additional incision is made in the lower belly or in the thigh to collect tissue that will used for the sling. A specialist may be needed to provide this option (it’s not as common as mid-urethral synthetic sling surgery). Autologous sling surgery is usually done through a cut in the bikini line. Or it can be done making a cut over the thigh. The surgery is most often done in less than 2 hours. This surgery does require more time to recover than a mid-urethral sling surgery. There are additional risks associated with this type of surgery. Talk with your surgeon about them.

Bladder Neck Suspension

Bladder Neck Suspension is also called Retropubic Suspension, Colposuspension or Burch Suspension.

In this surgery, sutures are placed in the tissue along the side of the bladder neck and urethra and attached to a ligament along the pubic bone. This supports the urethra and sphincter muscles to prevent them from moving downward and accidentally opening. There are certain risks with this surgery, as with all surgery, that should be discussed before making your decision. The surgery can be done open or laparoscopically under general anesthesia in less than a few hours. it requires more time to recover than mid-urethral sling surgery.