Stress incontinence:
why your pelvic floor helps more than any pad

1. What is stress incontinence?

In stress incontinence, urine leaks as soon as the pressure in the abdomen suddenly rises — when coughing, sneezing, laughing, lifting, jumping or climbing stairs. You don't feel an urge to urinate beforehand. The “stress” in the name refers to physical strain, not emotional stress — which is why German now calls it Belastungsinkontinenz, “strain incontinence”.^¹

The mechanism is a pressure problem: normally, the pelvic floor muscles, connective tissue and sphincter keep the urethra closed even under pressure. If they are weakened, or the urethra is no longer well supported, the pressure in the bladder briefly exceeds the closing pressure — and a few drops or a gush of urine escape.

Stress incontinence is the most common form of urinary incontinence in women and often appears after childbirth and during the menopause. In men, it mainly develops after prostate surgery.^¹,² Out of embarrassment, many people talk to no one about it for years and make do with pads. That is understandable, but a shame: in many cases, stress incontinence can be improved considerably.

2. Severity grades and how it differs from overactive bladder

The classic classification is based on the kind of strain that causes leakage:

• Grade 1: when coughing, sneezing or laughing.
• Grade 2: even when walking, standing up or lifting light loads.
• Grade 3: even when lying down or without any noticeable strain.

What matters most for treatment, however, is telling it apart from the other forms — because what helps with one is ineffective with another:

If the leakage comes mainly with a sudden urge to urinate, read the article on overactive bladder — bladder training and medicines are explained in detail there. Many women have a mixed form; in that case, the component that is more bothersome is usually treated first.

3. Symptoms and consequences

• Leakage under strain — typically at the very moment you cough, sneeze or lift something.
• No urge beforehand — the bladder gives no warning; the leak comes “out of nowhere”.
• Often combined with a feeling of prolapse — a sensation of pressure or of a foreign body in the vagina can point to a prolapse of the bladder or womb.

The consequences go beyond the physical: many people give up sport, avoid dancing or hiking, drink less out of fear and withdraw. Less exercise in turn favours weight gain, and drinking less leads to concentrated urine that irritates the bladder, and to constipation — both make the incontinence worse. Breaking this spiral is an important part of treatment.

4. Causes and risk factors

• Pregnancy and vaginal birth: the pelvic floor, nerves and connective tissue are stretched or injured — especially with large babies or forceps and vacuum deliveries.
• Menopause: the lack of oestrogen makes the mucous membranes and connective tissue around the urethra and vagina thinner and less elastic, see Menopause.
• Excess weight: permanently increases the pressure on the bladder and pelvic floor — one of the factors that is easiest to influence.
• Chronic coughing and straining: smoking, COPD, asthma or chronic constipation put strain on the pelvic floor with every cough and every push.
• Heavy physical work and sport involving jumping: lifting, trampolining, running on hard ground.
• Age and connective tissue: muscle strength and tissue tension decline over the years; some people naturally have weaker connective tissue.
• Operations: in men, above all radical removal of the prostate for cancer, less often procedures for benign prostate enlargement; in women, operations in the pelvis.

5. Diagnosis: bladder diary and cough test

The first point of contact is a gynaecology, urology or GP practice. The tests are usually simple and painless; they are meant to clarify the type of incontinence and rule out treatable causes.^¹

• Consultation and questionnaire: When does urine leak, how much, and since when? Births, operations, previous illnesses — and all your medicines.
• Bladder diary (voiding diary): For two to three days, note down how much you drink, trips to the toilet, leakage and triggers. It often reveals more than any memory.
• Urine test: A urinary tract infection can trigger or worsen incontinence and is ruled out first.
• Physical examination with a cough test: With a full bladder, you cough while the doctor watches whether urine escapes. Pelvic floor strength and any prolapse are assessed at the same time.
• Ultrasound: Shows whether urine remains in the bladder after you have passed water, and how mobile the urethra is.
• Bladder pressure measurement (urodynamics): Not needed for everyone — mainly before an operation, with mixed forms or if the findings are unclear.

How to prepare for the appointment is explained in the guide Prepare for a doctor's appointment. Take your bladder diary and your medication list with you.

6. Treatment: conservative first

The guideline is clear: treatment starts with conservative measures, and at their heart is supervised pelvic floor training. It has the best evidence of all non-surgical methods, no side effects — and only works if you stick with it.^¹,²

Which steps make sense, and in what order, depends on the severity, your age, family planning and how much the symptoms bother you. You make the treatment decision together with your treating practice.

7. Medicines: what they can and can't do

An honest look is worthwhile here, because in stress incontinence there is no medicine that replaces the pelvic floor.

Duloxetine: approved, but with a catch

Duloxetine is actually an antidepressant. Acting via messenger substances in the spinal cord, it increases the tension of the urethral sphincter, and it is approved in the EU for women with moderate to severe stress incontinence.^⁴ The effect is rather moderate, and many people stop treatment: nausea is very common, especially at the start, along with dry mouth, tiredness, sleep problems and dizziness. Mood changes and suicidal thoughts have also been reported. Duloxetine is therefore mainly an option when conservative measures are not enough and surgery is not wanted or not possible — after careful consideration with your practice.^¹

• Serotonin interactions: Together with other antidepressants, triptans or tramadol, the risk of serotonin syndrome rises.
• Raised drug levels: Certain inhibitors of the metabolising enzyme CYP1A2, such as the antibiotic ciprofloxacin, raise duloxetine levels considerably.
• Bleeding risk: With anticoagulants or painkillers such as ibuprofen, the tendency to bleed increases.

Bladder medicines for overactive bladder don't help here

Active substances such as oxybutynin, solifenacin or mirabegron calm an overactive bladder muscle. In pure stress incontinence, however, the problem is the closure, not the bladder muscle — so they achieve nothing, but still have side effects. They can be useful in mixed incontinence with a marked urge component.

Hormones: local yes, tablets no

Local oestrogens after the menopause can help. Hormone replacement therapy in tablet form, by contrast, is not a treatment for incontinence and can tend to make symptoms worse. More in the guide Hormone replacement therapy.

8. Surgery: slings, bulking, artificial sphincter

If conservative measures are not enough after a few months and the symptoms are very distressing, surgery is an option. It is very effective in women — but it is a procedure with its own risks that needs careful consideration.^¹

Men after prostate surgery

After radical removal of the prostate, many men leak urine at first. With pelvic floor training, this improves considerably for most of them over the course of the first year. If relevant incontinence remains, special male slings or — with pronounced leakage — an artificial sphincter are an option: a cuff around the urethra that is opened using a pump in the scrotum.^²

9. After childbirth and during sport

In the first weeks after giving birth, leakage is common and often improves on its own as tissues and muscles recover. Postnatal recovery exercise classes support this and are paid for by health insurance. If incontinence persists for months, targeted pelvic floor physiotherapy is worthwhile, rather than waiting for years.

When it comes to sport: don't stop, adapt. Jumping and running sports put heavy strain on the pelvic floor; cycling, swimming or strength training with conscious breathing are often better tolerated. A sports pessary or special tampons can help for certain activities. If you take medicines regularly and train a lot, you will find tips in the guide Medications and exercise.

10. Everyday life with stress incontinence

• Drink normally — drinking less makes the urine more concentrated, irritates the bladder and encourages constipation. Coffee and alcohol in moderation.
• Build the exercises into your day — at the traffic lights, while brushing your teeth, in the queue. Regularity beats intensity.
• Lift correctly — bend from the knees, keep the load close to your body, tighten your pelvic floor first and breathe out as you lift instead of holding your breath.
• Time your medicines wisely — water tablets in the morning rather than the evening, if your practice agrees; that way trips to the toilet don't fall during appointments or at night.
• Protect your skin — gentle cleansing, breathable pads and changing them regularly prevent sore patches.
• Measure your progress — keep a bladder diary again every few weeks. Fewer pads a day is a tangible success.

Stress incontinence is not a fate you simply have to accept with age or after having children. The most effective step is unspectacular: talk about it openly and take pelvic floor training as seriously as a tablet.

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