Considered one of the last taboos in American society, urinary incontinence is not a subject many women voluntarily discuss with their health care provider. The scope of the problem is enormous, affecting up to 25 million women in this country alone. Yet, the social embarrassment often keeps the sufferer at home and silent, trapped in bulky pads and believing that it is a normal part of aging. It is not a normal part of aging, and women do not need to suffer in silence. There are multiple different types of incontinence, but the majority of women have one of two main types known as stress urinary incontinence and urge incontinence. In stress incontinence, the leakage typically occurs while coughing, laughing, sneezing or engaging in physical activity such as exercise. For the urge variety, the leakage is due to uncontrolled spasm of the bladder muscle. These two general categories are treated in different ways, but sometimes therapies must be combined when there is a mixture of urge and stress leakage.

Urge Incontinence
In the case of urge incontinence, the bladder spasms may result from any number of causes including urinary tract infection, medications, certain foods and beverages, and a number of chronic diseases and medications. This condition is also known as overactive bladder, and there are varieties of treatment options for women whose urinary leakage is predominantly urge-related. Ruling out bladder infection is often the first action taken by a health care provider, and a simple culture of the urine will reveal the presence of bacteria. Antibiotic therapy is then prescribed, and the problem will be quickly resolved. Unfortunately, this is rarely an isolated cause, and other potential sources of the bladder irritation must be sought.

Once infection is treated or eliminated as a cause, the urgency symptoms can be treated with antispasmodic medications. There are several good choices on the market, and one need only watch the commercial ads accompanying the evening news to appreciate how the pharmaceutical companies vie for top honors in the incontinence market. All the medications used to treat urinary frequency, urge and leakage have consequences, and sometimes the side effects cause more trouble than they solve. For instance, constipation is common, although less so with the new drugs in this category. Also, dry mouth is highly reported and can lead to excessive intake of fluids, thereby complicating the problem of leakage. There are some simple alternatives to taking medication for incontinence problems, and these measures can be amazingly effective. For instance, avoiding certain foods that cause more bladder irritation such as tomatoes, citrus products and spicy dishes can lessen the number of trips to the bathroom and the number of leaking episodes. Caffeinated beverages including coffee, tea and sodas are bladder irritants as well as diuretics, giving rise to both more urine production as well as more bladder spasms – double trouble. It is preferable to drink water, rather than the other choices mentioned, but in moderate amounts of 5-6 glasses throughout the day. Avoiding any liquid intake for about two hours before bedtime lessens nocturnal urge/leak episodes.

For those who suffer from predominantly stress urinary incontinence, the medications that help with urgency symptoms are notoriously ineffective. However, if there is a mixture of stress and urge, medication can sometimes alleviate enough of the problem to keep the person dry. Since surgery is the most invasive treatment option for this, many health care providers will try medications as a first line regardless of type of incontinence, and more pharmaceutical choices are likely to become available in the not-too-distant future.

Stress Incontinence
The cause of stress incontinence is related to anatomic changes in the pelvic floor muscles and connective tissues that allow the urethra (the muscular tube channeling urine out of the body) to drop downward in relation to the body of the bladder. This displacement, typically worsening with deep cough or sudden sneeze, leads to a change in the normal pressure gradient between the urethra and bladder, and an “accident” results. Women who have delivered their children via vaginal birth are more apt to have this problem of prolapsed pelvic organs and stress incontinence, but being overweight and smoking are certainly contributing factors.

Other non-surgical options for stress incontinence have to do with strengthening of the pelvic floor muscles – Kegel maneuvers. These maneuvers are done by squeezing the same muscles that are responsible for stopping urine in mid-stream and holding the contraction for about ten seconds. You should do a series of these contractions at various times during the day on an ongoing basis. However, in order for these bladder exercises to be helpful, they must be performed regularly for a number of months, and many women are simply unable to keep up such a regimen.

There is also a technique of direct electrical stimulation of the pelvic floor muscles that allows for passive strengthening. A device is inserted vaginally that conducts an electrical impulse directly to the pelvic floor muscles, causing an involuntary contraction. When done repetitively, this therapy can literally build back muscle tissue, improve tone, and aid in maintaining continence. A related treatment for urge-related incontinence involves biofeedback of the bladder muscle contractions whereby patients can “learn” to reduce the number of bladder spasms with focused relaxation.

Regardless of the type of incontinence, retraining the bladder muscle to hold urine longer can lessen the number of incontinent episodes and reduce the overall volume of urine released if an accident occurs. This is accomplished by going to the bathroom by the clock over several weeks. The starting point is to urinate every two hours during the day. The time between voids is gradually increased in half-hour increments over the course of weeks such that the bladder is able to hold more volume with less spasms and leakage. Obviously, this form of timed voiding should be limited to daytime hours so as not to disturb sleep.

Sometimes, despite the best efforts to control the problem of urine loss with behavioral change, medication or even pelvic floor strengthening, the patient is left with the option of surgical correction. There are increasingly more effective and simpler procedures for correction of urethral hypermobility, and three basic approaches to correcting the sagging bladder/urethra problem. With one method, the bladder is “tacked” back into its former anatomical position through a vaginal incision. Gynecologists know this procedure as an “anterior repair.” It has a dismally high failure rate over time, and most surgeons now use it in combination with other techniques as opposed to an isolated bladder repair. The abdominal approach known as a retropubic urethropexy or Burch operation has a good long-term success rate, but the drawback is that of an abdominal incision and longer healing time. The newer urethral sling techniques allow for quicker healing, shorter hospital stays and much better long-term success rates using synthetic graft materials through a primarily vaginal approach. The sling acts as a barrier to keep the urethra from dropping far enough to allow leakage when the patient coughs, laughs, sneezes or lifts a heavy object. The only visible “incisions” are two small punctures just above the pubic bone in the midline , or on either side of the labia depending upon the particular type of sling that is being placed. The sling can be combined easily with other repairs of sagging vaginal walls or prolapsing uterus to correct all the pelvic floor problems at the same time.

It is clear that urinary incontinence in all its forms is a common and distressing problem with a multitude of contributing causes; however, there are many potential treatment options currently available and more are definitely on the way. As research moves forward in this area of health care for women, perhaps there will be less need to develop more effective absorptive products, and women can be free to pursue active lifestyles without fear of social embarrassment.

This article, authored by Jacqueline Thompson, MD, FACOG, appears in Radius magazine, Summer 2006. You can read more about Dr. Thompson and find additional health information at the Radius website www.radthemag.com.