Stress urinary incontinence occurs during periods of increased intra-abdominal pressure (e.g., sneezing, coughing, or exercise) when the intravesical pressure rises higher than the pressure that the urethral closure mechanism can withstand. Some advocate the term “activity-related incontinence” in some languages to avoid the confusion with psychological stress (8). Stress urinary incontinence is the most common form of urinary incontinence in women and is particularly common in younger women. Active women are more likely to notice symptoms of stress urinary incontinence. In a survey of 144 collegiate female varsity athletes, 27% reported stress incontinence while participating in their sport (11). The activities most likely to produce urinary loss were jumping, high-impact landings, and running.
Stress incontinence is an interesting “disease” as the same symptoms have varying effects on different women. This condition is best considered in a biobehavioral model that examines the interaction of three variables: (i) the biologic strength of the urethral sphincteric mechanism, (ii) the level of physical stress placed on the closure mechanism, and (iii) the woman’s expectations about urinary control. This model explains the enormous variation that exists among the symptoms, the degree of demonstrable leakage, and a patient’s response to her stress incontinence. Modification of any one of these factors may inﬂuence the patient’s clinical status; for example, many patients give up certain physical activities (e.g., running, dancing, aerobics) when they experience stress incontinence. Limiting their activities may eliminate the incontinence problem, but it does so at a certain cost to their quality of life. Other women learn to cope with stress incontinence by adopting new body postures during physical activities that prevent them from leaking or by strengthening their pelvic muscles to compensate for increased exertion. Other women may be profoundly relieved to find out that the small amount of leakage they experience from time to time is not abnormal. In any case, the interaction of these three biopsychosocial factors opens up a variety of strategies for the management of stress incontinence. Surgical intervention is only one strategy, and it addresses only the biologic competence of the sphincteric mechanism rather than either of the other factors that interact to produce the clinical problem.
Although stress incontinence is the most common type of urinary continence in all women, urgency incontinence is the most common form of incontinence in older women (12). Urgency urinary incontinence is the involuntary leakage of urine accompanied by or immediately preceded by urgency. The new joint report from the International Urogynecological Association and International Continence Society recommended this symptom be called urgency urinary incontinence to differentiate between the normal urge experienced when the bladder is full from the abnormal response that may require treatment.
This is a symptom-based diagnosis; the cause may or may not be detrusor overactivity, based on urodynamic observation characterized by involuntary detrusor contractions during the filling phase.
Women may have other related problems such as urgency, nocturia, and increased daytime frequency. The definition of nocturia is quantifiable: The woman wakes one or more times a night to void (8). Increased daytime frequency occurs when the patient considers that she voids too often. The term pollakisuria is used to describe this condition in many countries.
Urgency is the sudden compelling desire to pass urine that is difficult to defer. Most women have experienced these symptoms during times of voluntary delays in voiding or increased ﬂuid intake. However, urinary urgency implies more than just the feeling that all normal women have if they voluntarily delay voiding beyond a reasonable time (8). When a woman presents for treatment, she generally reports an intrusive, bothersome, persistent need to urinate that takes her attention away from other activities. Increased daytime frequency is often brought up as an issue when a woman experiences a change in her own voiding pattern.