Learning to exercise the right muscles:

1. Sit in a chair with your knees slightly apart. Imagine you are trying to stop wind escaping from your anus (back passage). You will have to squeeze the muscle just above the entrance to the anus. You should feel some movement in the muscle. Don't move your buttocks or legs.
2. Now imagine you are passing urine and are trying to stop the stream. You will find yourself using slightly different parts of the pelvic floor muscles to the first exercise (ones nearer the front). These are the ones to strengthen. If you are not sure that you are exercising the right muscles, put a couple of fingers into your vagina. You should feel a gentle squeeze when doing the exercise.

Doing the exercises:

1. You need to do the exercises every day.
2. Sit, stand or lie with your knees slightly apart. Slowly tighten your pelvic floor muscles under the bladder as hard as you can. Hold to the count of five, then relax. Repeat at least five times. These are called slow pull-ups.
3. Then do the same exercise quickly for a second or two. Repeat at least five times. These are called fast pull-ups.
4. Keep repeating the five slow pull ups and the five fast pull ups for five minutes.
5. Aim to do the above exercises for about five minutes at least three times a day, and preferably 6-10 times a day.
6. Ideally, do each five minute bout of exercise in a different position each time. That is, sometimes when sitting, sometimes when standing, and sometimes when lying down.
7. As the muscles become stronger, increase the length of time you hold each slow pull-up. You are doing well if you can hold each slow pull-up for a count of 10 (about 10 seconds).
8. Do not squeeze other muscles at the same time as you squeeze your pelvic floor muscles. For example, do not use any muscles in your back, thighs, buttocks, or stomach.
9. In addition to the times you set aside to do the exercises, try to get into the habit of doing pelvic floor exercises whilst going about everyday life. For example, when answering the phone, when washing up, etc.
10. After several weeks the muscles will start to feel stronger. You may find you can squeeze the pelvic floor muscles for much longer without the muscles feeling tired.

It takes time, effort and practice to become good at these exercises. You should start to see benefits after a few weeks. However, it often takes 8-20 weeks for most improvement to occur. After this time you may be cured from stress incontinence. If you are not sure that you are doing the correct exercises, ask a doctor, physiotherapist or continence advisor for advice.

If possible, continue exercising as a part of everyday life for the rest of your life to stop the problem recurring. Once incontinence has gone, you may only need to do 1-2 five minute bouts of exercise each day to keep the pelvic floor muscles strong and toned up, and incontinence away.

Sometimes a continence advisor or physiotherapist will advise extra methods. These are in addition to the above exercises. For example:

• Electrical stimulation. Sometimes a special electrical device is used to stimulate the pelvic floor muscles with the aim of making them contract and become stronger.
• Biofeedback. This is a technique to help you to make sure that you are exercising the correct muscles. For this, a physiotherapist or continence advisor inserts a small device into your vagina when you are doing pelvic floor exercises. When you squeeze the right muscles, the device makes a noise (or some other signal such as a display on a computer screen) to let you know that you are squeezing the correct muscles.
• Vaginal cones. These are small plastic cones that you put inside your vagina for about 15 minutes, twice a day. The cones come in a set of different weights. At first, the lightest cone is used. You need to use your pelvic floor muscles to hold the cone in place. So, it is a way to help you to exercise your pelvic floor muscles. Once you can hold onto the lightest one comfortably, you move up to the next weight, and so on.
• Other devices. There are various other devices that are sold to help with pelvic floor exercises. Basically, they all rely on placing the device inside the vagina with the aim of helping the pelvic muscles to exercise and squeeze. There is little research evidence to show how well these devices work. It is best to get the advice from a continence advisor or physiotherapist before using any. One general point is that if you use one, it should be in addition to, not instead of, the standard pelvic floor exercises described above.

Medication
Duloxetine is a medicine that is usually used to treat depression. However, it was found to help with stress incontinence separate to it's effect on depression. It is thought to work by interfering with certain chemicals that are used in transmitting nerve impulses to muscles. This helps the muscles around the urethra to contract more strongly.

One study showed that in about 6 in 10 women who took duloxetine, the number of urine 'leakages' were halved compared to the time before they took the medication. Therefore, on it's own, duloxetine is not likely to cure the incontinence but may help to make it less of a problem. However, duloxetine in addition to pelvic floor exercises may give a better chance of curing the incontinence than either treatment alone.

If you are past the menopause and take hormone replacement therapy (HRT), the oestrogen in the HRT affects the tissues around the vagina and urethra. This helps to improve the symptoms of stress incontinence in some women. However, HRT is not as effective as pelvic floor exercises in curing the problem.

Surgery
Various surgical operations are used to treat stress incontinence. They tend only to be used when the above treatments have not helped. The operations aim to 'tighten' or support the muscles and structures below the bladder. Surgery is often successful.

Some general lifestyle measures which may help

• Your GP may refer you to the local continence adviser. Continence advisors can give advice on treatments, especially pelvic floor exercises. If incontinence remains a problem, they can also give lots of advice on how to manage. For example, they may be able to supply various appliances and aids to help such as incontinence pads, etc.
• Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.
• Obesity. It is known that stress incontinence is more common in women who are obese. If you are obese, losing weight may help to ease the problem.
• Smoking can cause cough which can aggravate symptoms. It would help not to smoke.

Can stress incontinence be prevented?

It is thought that if you do regular pelvic floor exercises (as described above) after you have a baby, then stress incontinence is less likely to develop in the future.

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