Stress Urinary Incontinence (SUI)—Gun and Bullet Analogy

Andrew Siegel MD   11/18/17

With all the violence and senseless shootings in the USA, I hate to even mention the words “guns” and “bullets,” but they do offer a convenient metaphor to better understand the concept of stress urinary incontinence

Stress urinary incontinence (SUI) is a spurt-like leakage of urine at the time of a sudden increase in abdominal pressure, such as occurs with sneezing, coughing, jumping, bending and exercising. It is particularly likely to occur when upright and active as opposed to when sitting or lying down, because of the effect of gravity and the particular anatomy of the bladder and urethra. It is common in women following vaginal childbirth, particularly after difficult and prolonged deliveries.  It also can occur in men, generally after prostate surgery for prostate cancer and sometimes after surgical procedures done for benign prostate enlargement. 7. SUIIllustration above by Ashley Halsey from The Kegel Fix

Although not a serious issue like heart disease, cancer, etc., SUI nonetheless can be debilitating, requiring the use of protective pads and often necessitating activity limitations and restrictions of fluid intake in an effort to help manage the problem. It  certainly can impair one’s quality of life.

The root cause of SUI is typically a combination of factors causing damage to the bladder neck and urethra or their support mechanisms.  In females, pelvic birth trauma as well as aging, weight gain, chronic straining and menopausal changes weaken the pelvic muscular and connective tissue support.  In males this can occur after radical prostatectomy, although fortunately with improved techniques and the robotic-assisted laparoscopic  approach, this happens much less frequently than it did in prior years.

An effective means of understanding SUI is to view a bladder x-ray (done in standing upright position) of a person without SUI and compare it to a woman or man with SUI.  The bladder x-ray is performed by instilling contrast into the urinary bladder via a small catheter inserted into the urethra.

A healthy bladder appears oval in shape because the bladder neck (situated at the junction of the bladder and urethra) is competent and closed at all times except when urinating, at which time it relaxes and opens to provide urine flow.  An x-ray of the bladder of a woman or man with SUI will appear oval except for the 6:00 position (the bladder neck) where a small triangle of contrast is present (representing contrast within the bladder neck).  This appears as a “funnel” or a “widow’s peak.” With coughing or straining, there is progressive funneling and leakage.

normal bladder

Above photo is normal oval shape of contrast-filled bladder of person without SUI

female sui relaxAbove photo is typical funneled shape of contrast-filled bladder of female with SUI

male suiAbove photo is typical funneled shape of contrast-filled bladder of male with SUI following a prostatectomy

female sui strainAbove photo shows progressive funneling and urinary leakage in female asked to cough, demonstrating SUI 


The presence of urine within the bladder neck region is analogous to a bullet loaded within the chamber of a gun.  Essentially the bladder is “loaded,” ready to fire at any time when there is a sudden increase in abdominal pressure, which creates a vector of force analogous to firing the gun.

What to do about SUI?

Conservative management options include pelvic floor muscle training to increase the strength and endurance of the muscles that contribute to bladder and urethra support and urinary sphincter control.  Surgical management includes sling procedures (tape-like material surgically implanted under the urethra) to provide sufficient support and compression.  Sling procedures are available to treat SUI in both women and men.  An alternative is urethral bulking agents, injections of materials to bulk up and help close the leaky urethra. On occasion, when the bladder neck is rendered incompetent  resulting in severe urinary incontinence, implantation of an artificial urinary sphincter may be required to cure or vastly improve the problem.

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food


These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.



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One Response to “Stress Urinary Incontinence (SUI)—Gun and Bullet Analogy”

  1. Small Muscles With Big Impact: Insights Into PC Muscle Training | Our Greatest Wealth Is Health Says:

    […] the aging process, pelvic surgery and pelvic muscle weakness can contribute to post-void dribbling, stress urinary incontinence and erectile/ejaculatory dysfunction.  A strong pelvic floor helps prepare the female body for […]

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