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Background: Stress urinary incontinence (SUI) is generally thought to be a problem in aging, multiparous females secondary to trauma during childbirth, pelvic organ prolapse, and excessive mobility of the urethra. A number of healthy, athletic, nulliparous adolescent females presented with complaints of SUI. Our hypothesis is that athletic females who perform physically strenuous activity develop pelvic floor laxity that can be demonstrated on voiding cystourethrography (VCUG) performed in an upright position. Our objective is to report presenting symptoms, workup and treatment, and to analyze data in order to verify our hypothesis on an under-recognized but debilitating issue in this age group.
Methods: A retrospective chart review from 2000-2014 identified patients with SUI. Inclusion criteria were female gender, age < 18 years, and history of VCUG. Patients with a history of neurogenic bladder dysfunction were excluded. Data obtained included history of presentation, level of physical activity, physical exam, laboratory data, imaging, urodynamic testing, treatment and follow up.
Results: 28 females were identified with SUI. Median age was 14 years (5-16 years). Three had undergone an extensive negative workup including MRI, cystoscopy and retrograde pyelography, looking for an ectopic ureter as the cause of their incontinence. Sixteen had normal a VCUG. Twelve demonstrated bladder base descent well below the pubic symphysis either during a Valsalva maneuver or at rest on upright VCUG. The bladder necks appeared competent and did not funnel. Eleven girls described a history of intense physical activity including gymnastics, weight lifting and dance, 8 of whom demonstrated the correlating descent of the bladder on VCUG. Urodynamic testing performed in 15 revealed one with evidence of mild detrusor overactivity; the remaining 14 were normal. Twenty-one responded well to conservative measures such as pelvic floor strengthening exercises and biofeedback training, alpha-agonists, and timed double voiding. Seven required surgical intervention after all conservative measures failed. Five underwent Burch bladder neck suspension, one had an autologous fascial sling, and one had placement of artificial urinary sphincter, all with resolution of symptoms.
Conclusions: Stress urinary incontinence is a rare condition in the adolescent female that is likely under reported. Only 40% of our patients acknowledged strenuous physical activity. 73% of these patients demonstrated bladder descent on VCUG. While the exact cause and the best diagnostic studies are yet to be elucidated, our data suggests this entity should be considered and carefully evaluated with an upright VCUG to identify pelvic floor laxity in girls with symptoms of only daytime incontinence, especially with activity. Additionally, we recommend pelvic floor physical therapy as the initial treatment course.