Urinary Incontinence: The Health Problem Women Won't Talk About
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Urinary Incontinence: The Health Problem Women Won't Talk About

Millions of American women suffer from urinary incontinence. Yet this embarrassing problem is often surprisingly easy to fix.

A Secret Problem

Kathleen Quinlan was in her 20s when she had her first "accident." "I was doing jumping jacks in an aerobics class and I leaked a little," she says. "At the time I thought, no biggie -- I just switched to a lower-impact routine."

But little by little the urine leakage got worse. By the time Quinlan, a mother of four from Chicago, was in her 30s, she trickled urine whenever she sneezed, coughed, or horsed around with one of her kids. In her 40s the problem got bad enough that she had to stop dancing with her husband at parties and begin wearing sanitary pads every day "just in case." She once had a coughing fit and completely soaked her pants in the middle of a work seminar and had to rush home to change. Mortified, she told no one about her problem, not even her husband.

But when Quinlan, now 56, found that she was even leaking urine as she walked to the train for her daily commute, she finally made up her mind to get help.

"There's a sisterhood of silence when it comes to incontinence," says Linda Brubaker, MD, a professor of obstetrics, gynecology, and urology at Loyola University in Chicago. "Most women feel too self-conscious about the problem to discuss it openly, even with their doctors." In fact, women with incontinence endure symptoms for an average of six and a half years before they talk to a physician, according to the National Association for Continence.

That's a long wait for what turns out to be an amazingly common and often simple-to-fix problem. Urinary incontinence affects 28 percent of women ages 30 to 39, 41 percent of those 40 to 49 and almost half of all women 50 and older, according to a University of Washington survey of more than 3,000 women. And about 80 percent of these women can get complete or significant relief.

Why It Happens

Most leaky bladder problems (85 percent) are triggered by a weak urinary sphincter, the muscle located between the bladder and the urethra that acts like a seal to control the flow of urine. Called stress incontinence, the leaking is set off by coughing, sneezing, lovemaking, laughing, heavy lifting, jumping, running, and other types of exercise -- any activity that puts pressure on the abdomen and bladder, which in turn put pressure on the weak sphincter, forcing its seal to open. Urine loss can range from a few drops to a full stream.

The hallmark of stress incontinence is that after it's triggered by physical activity, it can hit without warning, as in Quinlan's case. By contrast, urge incontinence -- the less-common type, especially among women under age 60 -- makes you feel an intense need to void your bladder even if it isn't particularly full.

How do women develop a weak sphincter? The problem usually starts farther up, in the pelvic floor -- the hammock of muscles that supports the bladder, uterus, bowel, and vagina. When the pelvic floor is damaged or out of shape, all the organs it supports drop, straining the sphincter.

The pelvic floor can lose its tone for a variety of reasons. Sometimes weight gain strains the supporting muscles. Estrogen loss during menopause can weaken pelvic tissue and growing older further weakens muscle tone. A hysterectomy can also damage the pelvic floor's nerves and muscles. Then there's family history: "A woman may be at higher risk for weak muscles if her mother suffered from the problem," says Ingrid Nygaard, MD, professor of obstetrics and gynecology at the University of Utah School of Medicine. (Quinlan found out she had a family history of urinary incontinence.)

Vaginal childbirth has been linked to stress incontinence, too. But even if you have never given birth or you delivered via cesarean section, you can still develop the problem.

One surprise finding? The risk of stress incontinence goes up within four months of beginning menopausal hormone therapy, according to a University of California at Davis and University of California, San Francisco study. A possible explanation is that hormone therapy decreases the amount of collagen around the urethra, leading to a looser seal.

Getting Help

Diagnosing stress incontinence usually isn't difficult if your physician does a thorough examination. "Many doctors don't take the time needed to identify your problem accurately," says G. Willy Davila, MD, chairman of gynecology at the Cleveland Clinic Florida in Weston. "They may recommend the wrong treatment."

Be especially wary if your doctor's first response is to write a prescription. The incontinence medications you hear about on TV are generally for urge incontinence and won't help stress incontinence.

If nondrug remedies don't work, there are prescription medications your doctor can try later in your treatment. If your problem is severe you may eventually need to see a urogynecologist, an ob-gyn who specializes in treating women with pelvic-floor dysfunction. For help finding one, go to the American Urogynecologic Society's Web site (www.augs.org) or visit www.mypelvichealth.org.

Treatments
Therapies to treat stress incontinence range from simple and noninvasive to surgical repair. Start with the basic remedies and see if they give you some relief.

Cross Your Legs
This may be the universal posture of bladder distress, but it actually works, preventing embarrassing dribbles in 73 percent of women, researchers report. Whether you're standing or sitting, cross your legs and bend slightly forward whenever you feel a cough, sneeze, or hearty laugh coming on.

Train Your Pelvic-Floor Muscles
A 2004 study found that 49 percent of test subjects benefited from Kegel exercises. Most likely to be helped? Women with fewer than two leaking episodes a day. "Yet 99 percent of the women who walk into our center insist that Kegel exercises don't work," says Diane K. Newman, MSN, codirector of the Penn Center for Continence and Pelvic Health at the University of Pennsylvania Medical Center. "That's because most women do them incorrectly. Once a woman learns the right way to Kegel, the results can really be dramatic."

To find the right muscles to use, lie down, insert one or two fingers into your vagina, and contract your pelvic-floor muscles as if you were trying to stop urine flow; you should feel pressure on your fingers. One of the best ways to do Kegel exercises is to gradually contract these muscles for a count of four and then hold the contraction for another count of four. It takes about eight to 12 weeks of doing Kegels regularly (about five minutes, twice a day) to see results.

More Treatments

Lose Weight
Dropping as little as 5 percent of your body weight (about 7 pounds if you weigh 140, for example) could decrease your weekly leaking incidents by almost 60 percent, according to a 2005 study.

Wear a Tampon When You Exercise
Tampons push on the vaginal wall, which compresses the urethra. This pressure stops or minimizes leaks that occur during a workout. In one study, using tampons worked for more than half of women with mild incontinence. To make inserting and removing a tampon after exercise easier, cover it with a lubricant like K-Y Brand Jelly.

Use a Pessary
This device, worn inside the vagina, resembles a diaphragm and helps support the bladder and compress the urethra, reducing accidents. Women with stress incontinence can use one when they're doing specific activities that lead to leakage and remove it afterward. Research suggests that about half of women who try a pessary continue to use it and find it effective. Made of flexible silicon and easy to insert and remove, they cost anywhere from $30 to $120 and often are covered by insurance.

The most common side effects are increased vaginal odor and discharge, but you can usually avoid this problem if you remove and clean the device with soap and water at night. (Some women may be prescribed a different type of pessary designed to be inserted and removed by a physician.)

Try Medication
Although bladder medication doesn't work for stress incontinence, doctors report that off-label use of the prescription antidepressant imipramine can sometimes increase the tone of the urethral sphincter muscle, reducing urine loss. It's most effective when you take it in combination with estrogen cream or suppository tablets, though imipramine can be taken alone, according to Dr. Davila. You may notice some side effects such as nausea, drowsiness, and dry mouth. "Patients may notice an improvement within two to three weeks," he adds.

Get Injections
Your doctor can inject natural collagen protein or other materials into the tissues around your urethra to restore its seal. This procedure, which is used for more severe forms of stress incontinence, takes only about 15 minutes and is usually done under a local anesthetic in a doctor's office. The chief downside is that some materials gradually dissipate. To keep the seal firm, you may need to have an injection every six months to two years. Other materials last longer, so check with your doctor for further information. The injections cost about $1,000 and are covered by most insurance plans.

The Option of Surgery

Surgery is a good option if none of the less-invasive methods succeed. Older procedures generally involve stitching or suturing the pubic-bone ligaments that hold up the bladder so they're tighter. Most require you to stay overnight in the hospital, and long-term success rates are 75 to 90 percent. Doctors now have the option of operating through the vagina, which might allow you to go home the day of your surgery. In these procedures a doctor implants a sling, made either of your own connective tissue (called a fascial sling) or of surgical mesh, to support the urethra and other structures. Synthetic slings have proved more popular because the operation to implant them is faster and less invasive than creating a sling from tissue.

That could change, however: In October the FDA issued a notification that synthetic surgical mesh used for operations to treat stress incontinence (and also urinary prolapse) has been associated with more than 1,000 reports in the past three years of complications such as infection, pain, erosion through the vagina, urinary problems, and painful sex. Some women needed further surgery that may not always be successful at correcting their postoperative problem.

"The two slings are probably comparable in terms of efficacy, but the synthetics may lead to complications that can affect a woman's lifestyle and are very difficult to treat," says Jerry G. Blaivas, MD, clinical professor of urology at Weill Medical College of Cornell University, in New York City. He believes that the fascial sling, despite the bigger incision and need to have a longer operation, is the gold standard.

Many of these procedures are too new to have established long-term success rates. "There are pros and cons to every procedure, which your doctor should carefully review with you," says Dr. Brubaker.

Having surgery six years ago changed Kathleen Quinlan's life. "I hadn't realized how much fear I was living in every day or how much I was avoiding doing things because of worries about my condition," she says. "Now I don't have to wear pads, I can work out at the gym, and I can even dance with my husband again!"

The Other Reason Accidents Happen

It's called urge incontinence or overactive bladder for a reason: You feel a sudden, overpowering urgency to urinate right now. You may not necessarily leak urine -- in fact, you may produce no more than a few drops when you visit a restroom. But chances are your life is ruled by the need for frequent trips there.

Although no one knows for certain, one leading theory is that urge incontinence is triggered by an age-related change in nerve or chemical signals to the muscle cells of the bladder. This may explain why the problem is more common in older women, many of whom also suffer from stress incontinence.

Your first response? Begin behavioral techniques including limiting excessive fluids. The rule of thumb is "drink to quench thirst." "I see women who walk around drinking liters of water all day long," says the University of Pennsylvania's Diane K. Newman, MSN. "This can overstretch your bladder and lead to urgency." A tactic called bladder-control training can also help extend the time between bathroom trips by using Kegel exercises to hold back urine for 15 minutes, then increasing the delay until you can last two to three hours. One study found this cut the number of urgent episodes by 57 percent.

Several medications help relax bladder muscles and lessen the frequency of sudden urges. The most commonly prescribed pills are Detrol LA (long-acting), Enablex, Vesicare, and Sanctura, as well as a patch called Oxytrol. "A woman usually gets the best results when she combines a variety of behavioral measures with a medication," notes Newman. Side effects of most urge incontinence drugs include constipation and dry mouth.

Using a prescription low-dose vaginal estrogen cream (such as Premarin or Estrace) may also help: "It improves blood flow to the urethra and vaginal areas, helping to strengthen the tissue," says Dr. Davila. You insert the cream into your vagina with an applicator two or three times a week. Vaginal estrogen tablets are also effective.

Finally, for severe urge incontinence, if other options don't work, doctors can surgically implant a neurostimulator, which is like a "bladder pacemaker" designed to decrease bladder contractions and the resulting urgency and frequency. It costs about $14,000 and is usually covered by insurance. Research shows 80 percent of women who had the procedure got at least some relief from their incontinence.

Originally published in Ladies' Home Journal, January 2009.

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