Stress Urinary Incontinence




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ICS Definition:

  • Complaint of involuntary loss of urine on effort or physical exertion including sporting activities etc, or on sneezing or coughing. “Activity-related incontinence” might be preferred in some languages to avoid confusion with psychological stress.

Screening Questions:

  • Does leakage occur with a cough / sneeze?

  • Does leakage occur with exercise or physical activity eg; lifting or bending over?

  • Does leakage occur with change of position eg; sit to stand?                        

Red Flags:

Further investigation or referral to specialist is indicated when incontinence is associated with, or accompanied by:

  • Persistent or recurring urinary tract infections.

  • Dysuria, persisting bladder or urethral pain.

  • Haematuria, glycosuria or persistent proteinuria.

  • Inability to empty bladder or straining to empty.

  • Post void residual volume >200ml.

  • Nocturnal enuresis.

  • Rectal bleeding or unexplained vaginal bleeding.

  • Recent sudden alteration of bowel habits with no obvious explanation.

  • Persistent vulvo-vaginal itching area or undiagnosed vulval or rectal dermatological conditions.

  • Pelvic organ prolapse (POP) past introitus causing difficulty emptying bladder.

  • Pelvic masses, unexplained weight loss or unremitting night pain.

  • Suspected neurological disease e.g. MS, Parkinson’s disease, stroke, dementia or spinal cord symptoms, such as muscle weakness/wasting, altered reflexes, altered sensation (generally and saddle region), inability to empty bladder, loss of sensation when voiding.

  • Suspected urogenital fistulae.

Initial Testing / Examination

  •    Pelvic examination.

  •    Cough stress test on pelvic exam.

  •    Urinalysis.

1st Line Treatment

Refer to an appropriate health professional:

  • Continence and Women’s Health Physiotherapist:

    • Pelvic floor muscle training based on an individualised program.

    • Biofeedback including real-time ultrasound, Peritron, EMG.

    • Lifestyle modifications.

    • Adjuvant physiotherapy techniques: vaginal weights, cones, spheres.

    • Vaginal support pessary.

  • Continence Nurse Advisor.

  • In some cases, it may be appropriate to refer to both Continence Nurse Advisor and Continence and Women’s Health Physiotherapist. These roles may complement and work together to help the patient achieve optimal management.

 2nd Line Treatment

Refer to subsequent Allied Health Professional:

  • Dietetics.

  • Asthma Educator.

  • Respiratory Physiotherapist.

  • Diabetes Educator.

  • Occupational Therapist.

 3rd Line Treatment

The referral to the following medical specialty is appropriate if the patient shows Red Flag signs or is non-responsive to conservative management.

  • Urologist / Gynaecologist / Urogynaecologist:

    • Midurethral sling.

    • Bladder suspension surgery with or without POP repair.

    • Urethral Bulking agents.


  • Either acute or chronic respiratory condition including hay fever, asthma, sinusitis, COPD.

Medical Intervention:

  • Review of / introduction of medication.

  • Is the management optimal?

  • Refer to Asthma Educator, Respiratory Physiotherapist or Specialist for review.


  • Obesity is a major contributing factor to SUI. Moderate weight loss when combined with exercise is likely to be effective in reducing SUI.

Medical Intervention:

  • Advice/refer to Dietitian.


  • Some medications may cause side effects including increased coughing, weight gain and constipation which may aggravate SUI.

Medical Intervention:

  • Review of medications which may impact on bladder and bowel health.


  • Constipation and repetitive straining to evacuate bowels may cause pelvic floor dysfunction, and thereby contribute to SUI.

Medical Intervention:


  • Hormonal changes in the postpartum and peri/post-menopausal women may contribute to SUI.

Medical Intervention:

  • Consider topical oestrogen support if appropriate.


  • Repetitive heavy lifting as well as strenuous or poorly performed exercises may contribute to SUI.

Medical Intervention:


  • Poor fitness levels and minimal physical activity.

Medical Intervention:


  • Lumbo-pelvic pain has a strong association with SUI.

Medical Intervention:

  • Refer to Musculoskeletal Physiotherapist.


  • SUI may be a consequence of UTI.

Medical Intervention:

  • Assess and treat for UTI as required.