The pelvic floor muscles are a group of muscles designed to support the bladder, vagina, and rectum. Under normal circumstances these muscles automatically contract when abdominal pressure increases (e.g. with coughing, sneezing etc.) to compress the urethra and maintain a tight seal. In this way these muscles are critical in maintaining continence. By returning these muscles to a normal strong state urinary incontinence can often be dramatically improved or cured. Like any conditioning program the muscles of the pelvic floor are strengthened by exercise. It is very common, however, for women to have difficulty locating the correct muscles without some form of instruction from a health care provider. This is where biofeedback comes in. Biofeedback uses a video display of the activity in the pelvic floor muscles to make patients aware how well they are isolating this group of muscles. It is very common to use the abdominal, buttock, and thigh muscles instead of, or in addition to, the pelvic floor muscles when first attempting these exercises. This amounts to a waste of energy and may even be harmful to the already weak pelvic floor.

Additional benefit may be gained through passive exercise of the pelvic floor muscles using electrical stimulation. This is not a painful experience and for patients with very weak pelvic muscles this is often the only way to begin the process of rehabilitation. Typically a small vaginal electrode (about the size of a tampon) is used to stimulate the muscles surrounding the bladder, vagina, and rectum. This treatment is performed once a week for six to eight weeks along with a program of home pelvic floor exercises.

Estrogen plays a vital role in the normal functioning of the vagina and urinary tract. The urethra is extremely sensitive to estrogen and often will not function normally without it. After the menopause even if a woman takes estrogen replacement the urethra may not be stimulated enough to function normally. Topical estrogen in the form of a suppository or cream can produce a dramatic effect on the urethra in terms of how tight a seal it is able to maintain. Topical estrogen has very few side effects, is safe, and is not associated with an increased risk of breast cancer.

A pessery is a device worn inside the vagina to compensate for a poorly supported urethra, bladder, uterus, or rectum. One common form looks much like a contraceptive diaphragm and generally can be inserted and removed by the patient. The effectiveness of this device in treating urinary incontinence is debatable. Once inserted periodic visits to the gynecologist are important to ensure that the device is not irritating the vaginal walls.

Although there are many safe and effective non-surgical treatment options patients with severe stress incontinence often elect to have a surgical procedure. Although these procedures are safe and very effective patients must be aware that every surgical procedure has risks. Further, it should be understood that surgery sometimes fails to correct the problem and that when successful sometimes symptoms return months or years latter.

The two most commonly performed surgical procedures for stress incontinence are the Burch procedure, and the sub-urethral sling. The Burch procedure is performed through an abdominal incision or in some cases laparoscopicaly (band-aid surgery). This procedure reattaches the tissue beside the urethra to the bones of the pelvis thus recreating a well-supported urethra. The surgery is quite effective with most patients cured or dramatically improved for at least five years. The sub-urethral sling procedure likewise supports the urethra by placing a sling if tissue around the urethra via combined abdominal and vaginal incisions. This procedure, like the Burch, has been very successful and well tolerated over the years. A newer form of sling operation called the tension free vaginal tape (TVT) procedure has the advantage of being somewhat less invasive and thus affords a quicker recovery time. It is not interlay clear if there are long term risks associated with the sling material used in the TVT but thus far the procedure appears to be very safe.

Finally some patients with stress incontinence due to a poor urethral seal can be helped, at least temporally, by having collagen or another “bulking agent” injected around the upper portion of the urethra. This procedure can be performed in the office or operating room on an outpatient basis.

The most important thing you can do to improve you bladder symptoms is to speak to a physician about the problem.