Fellowship-Trained Urogynecologist
Urogynecology & Reconstructive Pelvic Surgery
Green Bay, Wisconsin
✓ Medically reviewed May 14, 2026
What causes stress urinary incontinence?
Stress urinary incontinence (SUI) is the type of leaking that happens when you cough, sneeze, laugh, lift, or exercise. Despite the name, it has nothing to do with emotional stress. The word “stress” refers to physical pressure on your bladder.
SUI is common. About one in three adult women leak at least weekly. Prevalence peaks between ages 45 and 49, then gradually drifts down. About half of young women who haven’t had children report occasional leaking during vigorous exercise, so it’s not just an older-woman problem.
Two systems keep you dry
Your body uses two systems working together to prevent leaking.
The first is your urethral sphincter. This is the muscle and tissue that holds the urethra closed from the inside. It has three parts that each contribute about equally: striated (voluntary) muscle, smooth muscle, and a blood-vessel cushion that helps form a watertight seal. In younger women, resting closure pressure is around 100 cm H2O. By the time you’re older, it can drop to around 30 cm H2O. That decline makes leaking more likely.
The second is the support system underneath your urethra. Your pelvic floor muscles, connective tissue, and vaginal wall form a hammock-like layer. When you cough, abdominal pressure pushes down on your urethra and squeezes it closed against this firm backstop. Think of it like stepping on a garden hose lying on a sidewalk: the hose closes because the surface underneath is firm. If that surface is soft, the hose just sinks in and water keeps flowing.
When either system is weakened, or both, leaking happens.
Common causes and risk factors
Pregnancy and vaginal delivery are the single biggest risk factor. Delivery can stretch and damage the pelvic floor muscles, nerves, and connective tissue. Pudendal nerve injury during birth reduces urethral closure pressure. Women who leak during pregnancy are about 3.5 times more likely to have postpartum incontinence, suggesting some women have a baseline pelvic floor vulnerability.
Menopause and hormonal changes also play a role. Declining estrogen thins the urethral and vaginal tissues. The blood-vessel cushion in the urethra is sensitive to estrogen, and when that support shrinks the seal gets weaker.
Obesity has a dose-response relationship with SUI. Compared to women with a normal BMI, women with a BMI of 30 to 34 have about three times the risk, and women with a BMI over 40 have about five times the risk.
Chronic pressure on your abdomen from repeated coughing (asthma, smoking), heavy lifting, or straining with constipation wears down support over time.
Previous pelvic surgery, including hysterectomy, can change pelvic support.
Connective tissue differences matter too. Some women have naturally weaker collagen. Women with joint hypermobility and SUI tend to have lower total collagen content, even when they’ve never had children.
Aging reduces muscle mass and tissue elasticity. Urethral closure pressure starts declining after age 36 and continues throughout life.
It’s usually a combination
Most women don’t develop SUI from one cause alone. You might have some pelvic floor weakening from childbirth, then hormonal changes after menopause reduce tissue support further, and a chronic cough adds ongoing strain. Each factor chips away at the system.
Understanding your specific contributing factors helps me build a better treatment plan with you. If we can address things you can change, like managing your weight or treating a chronic cough, that often improves the results of other treatments too.
Treatment options we can talk about
Because SUI involves both support and sphincter problems, there are several treatment approaches. The right choice depends on your goals, your anatomy, and how much the leaking bothers you.
Pelvic floor physical therapy works on more than just strength. A trained pelvic floor PT helps with muscle coordination, timing (learning to contract before you cough), relaxation, endurance, breathing patterns, and posture. In research studies, women who worked with a PT were about eight times more likely to report being dry compared to women who did nothing. We have pelvic floor PTs in our office who can work with you directly.
Weight loss of 5 to 10 percent of body weight can cut SUI episodes by more than half.
A continence pessary is a small device you wear in the vagina to support the urethra. About 92 percent of women can be successfully fitted.
Urethral bulking is a minimally invasive procedure I can do in the office under local anesthesia. A gel is injected around the urethra to help it seal better. It’s a good option for women who want to avoid major surgery or have health conditions that make surgery risky.
A midurethral sling is the most common surgery for SUI and has strong long-term results. It places a small piece of mesh under the urethra to restore support, much like rebuilding the firm backstop.
There’s no rule that says you have to try conservative options before considering surgery. Guidelines support all of these as legitimate first-line choices. We’ll figure out together what makes sense for you.
References
- DeLancey JOL. The pathophysiology of stress urinary incontinence in women and its implications for surgical treatment. World J Urol. 1997;15(5):268-274.
- Ashton-Miller JA, Howard D, DeLancey JOL. The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl. 2001;(207):1-7.
- Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol. 2004;104(3):607-620. doi:10.1097/01.AOG.0000137874.84862.94
- Kobashi KC, Albo ME, Dmochowski RR, et al. Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline. J Urol. 2017;198(4):875-883. doi:10.1016/j.juro.2017.06.061
- Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019;31(6):485-493. doi:10.1097/GCO.0000000000000584
- Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009;360(5):481-490. doi:10.1056/NEJMoa0806375
- Wu JM. Stress incontinence in women. N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037
- Fleischmann N, Chughtai B, Plair A, et al. Urethral bulking. Female Pelvic Med Reconstr Surg. 2024;30(11):658-666. doi:10.1097/SPV.0000000000001548
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