Our “Treatment Trifecta” Against Stress Urinary Incontinence

CU urogynecologists apply a simple treatment philosophy to help women suffering from stress urinary incontinence get back on their feet and enjoy the things they love.

Women with stress urinary incontinence enjoying ice skating | CU Urogynecology | Aurora, COPelvic floor disorders can be complex conditions, involving interactions between our genetics, lifestyle and medical conditions. When women come to our practice with a pelvic floor problem, such as stress urinary incontinence, we address their concern in a multidisciplinary fashion to focus on all aspects of their condition.

There are three key components we aim to hit in improving a woman’s life when she is suffering from stress urinary incontinence. We call these elements our treatment trifecta, and they include:

  • Achieving a strong pelvic floor to squeeze on the urethra when we need it to close.
  • Aligning the bladder and urethra in the upright proper position.
  • Having the urethra stay closed when you are not urinating.

It is important that women know we have a range of treatment options to help with each problem. If you are accidentally leaking urine when coughing, sneezing, laughing or during physical activity, it is time to seek professional help.

The first step to help with stress urinary incontinence is to talk to your doctor about your symptoms. We can go over how you are affected and make sure you have the best treatment plan for you that focuses on the three key goals. Learn more about each goal and the treatment options below.

How to attain a strong pelvic floor

Most women at some point in their lives have been told that it is important to have a strong pelvic floor, which is the group of muscles on the floor of the pelvic area. But do you know why?

The pelvic floor muscles’ main role is to support the organs in the pelvis and give us control over our bladder and bowels. Poor support can result in all kinds of unpleasant problems, including stress urinary incontinence.

The pelvic floor muscles and pelvic support connective tissues can be weakened due to pregnancy and childbirth, chronic coughing, straining on the toilet, heavy lifting, obesity, doing high impact exercises, or simply age. When the pelvic floor muscles and the connective tissues that hold the urethra and bladder in position weaken, the internal organs are not fully supported and can shift out of place. This can lead to difficulty controlling the release of urine, feces or gas (flatus). When the urethra moves out of place, this leads to stress urinary incontinence.

What’s really good about this segment of our treatment trifecta is that you can do something about your pelvic strength by yourself. And we can also do many things medically and surgically to give a woman a stronger pelvic floor and prevent leakage with activities.

Treatment to improve the pelvic floor includes behavioral changes, Kegel exercises, physical therapy and electrical stimulation of the muscles. You can do the first two right in your home!

Surgery can also be performed to help support the urethra, and that’s part of the trifecta element of keeping the organs in the right place (see below). One of our urogynecologists can go over each option with you, and together you can land on the best way to improve your pelvic floor. Following are four treatments to achieve a strong pelvic floor.

Maintaining a healthy lifestyle

One of the first lines of treatment to achieve a strong pelvic floor is changing behaviors to maintain a healthy lifestyle. This could include any of the following behavioral changes.

  • Avoid pushing or straining when urinating or having a bowel movement.
  • Eat a pelvic floor friendly diet (read more about that in this blog).
  • Drink the appropriate amount and types of liquid.
  • Lose weight if you are overweight.
  • Avoid repetitive heavy lifting and learn proper lifting techniques that include activating the core and pelvic floor muscles.
  • Quit smoking.

Kegels for strengthening the pelvic floor muscles

Studies have shown that women with incontinence have underlying issues with pelvic floor muscle strength. Therefore, strengthening these muscles is key in treating stress urinary incontinence and preventing future problems.

Kegels are an excellent and easy contraction exercise for the woman’s pelvic floor. Kegels can prevent and cure conditions that are caused by weak pelvic floor muscles. So you can do the preventing and curing with the same exercise. It can take 1-3 months of consistent practice before a woman will start to see the benefits from Kegels.

Physical therapy for a stronger pelvic floor

Sometimes, it can be difficult to isolate the pelvic floor muscles in order to strengthen them, making it tough for a woman to do Kegels at home properly. A physical therapist can work with you to provide exercises to help identify and activate these muscles. These could include Kegels and other pelvic floor exercises, and a physical therapist can also help with massages or stretching to build strength.

The therapist can also perform biofeedback, which is a nonsurgical, pain-free technique that uses sensors and video to help identify which muscles are not contracting. The therapist will direct the treatment to get those muscles to start working better.

Many muscles have to work together in our body, and the pelvic floor is no different. The main muscles that work in coordination with the pelvic floor are the core and hip muscles. If there are issues with these muscle groups, a physical therapist can identify this, and assist with making these accessory muscles function better as well.

A physical therapist can also treat patients with electrical pulses that are used to strengthen the pelvic floor muscles. This is a pain-free way to help stimulate contractions when the muscles are weak and the patient cannot contract on her own.

Keeping the pelvic organs in the right place

The second part of our treatment trifecta is to make sure a woman’s pelvic organs are in the right place. The pelvic organs include the bladder, rectum, vagina, urethra and uterus (womb). These organs are held in place by tissues called fascia, ligaments and pelvic floor muscles. If the pelvic organs are not in the right place, they may bulge down into the vagina, also known as prolapse. If the urethra moves out of its position, women may experience stress urinary incontinence.


A nonsurgical option to help keep the organs in the right place is a pessary. This is a silicone device that fits into the vagina to support the placement of your pelvic organs. This is a good option for someone who is not interested in or eligible for surgery, or for a woman interested in having additional children, which could cause the organs to move out of place again.

Some pessaries are specifically designed to give extra support to the urethra to help prevent stress urinary incontinence. Depending on the severity of the stress urinary incontinence, they can be used daily or during high impact activities to help prevent leakage.


Multiple surgical options can help women who are having problems with stress urinary incontinence due to out of position organs, after trying the nonsurgical options mentioned above. The three most common surgeries that we perform at CU Urogynecology are a mid-urethral sling, Burch colposuspension and fascial sling.

  • Mid-urethral sling. This treatment places a sling under the middle portion of the urethra and behind the pubic bone.
  • Burch colposuspension. This operation places stitches in the vagina on either side of the urethra and ties these stitches to supportive ligaments to elevate the vagina.
  • Fascial sling. This operation places a sling of connective tissue from the abdomen or from the thigh under the urethra and behind the pubic bone.

Helping to keep the urethra closed and reduce stress urinary incontinence

The third and final part of the treatment trifecta is to insure the urethra opens and closes properly, because when it does not close correctly, urine can leak. The urethra’s job is to stay closed so the bladder can fill, and then to open when it is time to urinate so urine can pass outside the body.

The urethral sphincter muscles can become weak from aging, vaginal delivery or previous surgery near the urethra. The lining inside of the urethra can also become thin when estrogen levels decline with menopause.

When the urethral sphincter muscle isn’t contracting well, or when the urethral lining is thin, the urethra can remain slightly open. This will cause urine to leak continuously or with activities that usually cause very little pressure on the bladder, such as walking or bending over.

There are multiple treatment options if a woman’s urethra becomes weak including medications, urethral bulking and surgery.

Urethral bulking

During a urethral bulking treatment, an agent is injected around the inside of the urethra so that the walls of the inner urethra touch to help obtain a “seal” again and keep the urethra closed. Common bulking agents include different substances in water-based gels. The procedure can be performed in our office under local anesthetic.

This procedure may need to be completed several times in order to provide long-term relief. Urethral bulking is a great option for women who are not a fit for surgery or who have not completed their family.


Two medications can help the urethra close better: vaginal estrogen and duloxetine. Using small amounts of estrogen in the vagina can help the inner urethral lining to become thicker, so that the inner walls touch and create a better seal. Duloxetine is an antidepressant that has been shown to help the urethral sphincter muscles close tighter. It is best to talk with a doctor about medications because each one has its own benefits and side effects.

Ready to try our treatment trifecta for stress urinary incontinence?

Now you know about the treatment trifecta that we aim for with our patients. By focusing on these three areas, we can help our patients get back to the things they love and not have to worry about an accidental leakage – or where the closest bathroom is at all times.

Make an appointment