Female Urinary Incontinence: Don’t Suffer in Silence?>

Female Urinary Incontinence: Don’t Suffer in Silence

by Tim Gower

Urinary incontinence (UI) can leave you fearing loss of bladder control every time you cough or laugh. Or planning your days so that you’re never too far from a restroom. If you have UI, you know that this involuntary loss of urine can disrupt your life and lead to awkward social situations. It can also increase your risk for falls (due to hasty trips to the toilet), leave you depressed, and interfere with sexual intimacy.

Yet only about one in four women with UI seek medical help, either because they’re too embarrassed or because they think UI is just a part of normal aging. That’s not the case, however, and while pads and special undergarments can help you cope with “leakage,” a variety of treatments can help curb the condition, including lifestyle changes, behavioral therapy, medications, and minimally invasive surgery.

If you have UI, your bladder sometimes fails to retain urine until you’re ready to void through the urethra—the tube that transports urine out of the body. An estimated 17 percent of American women ages 20 years and older have moderate to severe UI, and that figure more than doubles among women over 60, says a 2017 review in JAMA: The Journal of the American Association.

UI is more common in women than in men because childbirth and gynecological procedures like hysterectomy can damage pelvic floor muscles needed for bladder control, and menopause leads to a loss of estrogen, which can cause supportive tissue around the urethra to become weak.

Incontinence risk factors

Being a woman and aging are the major risk factors for urinary incontinence.

Others include:

  • Obesity (a body mass index of 30 or higher)
  • Chronic constipation
  • Participation in activities with a lot of running and jumping
  • Smoking
  • Use of diuretics (such as for high blood pressure) or certain other drugs

Types of urinary incontinence

There are three primary forms of UI:

  • Urge incontinence is characterized by a sudden, overwhelming urge to urinate, followed by leakage if you can’t make it to a toilet in time. The problem appears to be brought on by the misfiring of bladder muscles and nerves that control the urinary system. Urge incontinence can be triggered by acts as simple as drinking a beverage, putting a key in the door when you arrive home, or hearing the sound of running water. Urgency may be accompanied by frequent urination, defined as voiding more than eight times a day and once at night.
  • Stress incontinence can make coughing or laughing—or sneezing, exercising, or lifting heavy objects—perilous. Activities like these increase abdominal pressure on the bladder, which can produce urine leakage if the pelvic floor muscles that normally prevent urine outflow are weakened.
  • Mixed incontinence is the combination of more than one type of incontinence.

Other forms of incontinence include overflow UI, which is the involuntary release of urine from an overfilled bladder and more common in men than in women. Functional UI is caused by difficulty getting to the toilet due to physical or cognitive restrictions, such as using a wheelchair or having Alzheimer’s disease.

UI can also be triggered by some medical conditions, such as urinary tract infections, strokes, and Parkinson’s disease.

Changing lifestyle and behavior

Doctors usually recommend lifestyle changes, behavioral therapy, and specific exercises as first-line treatment for controlling UI. And for good reason: A review of 84 clinical trials published in April 2019 in Annals of Internal Medicine found that behavioral therapy is more effective than medication for both stress and urge incontinence. You should expect to see improvement within about four to six weeks after beginning strategies like the following:

  • Learn Kegel exercises. Also known as pelvic floor muscle exercises, regular Kegel workouts strengthen pelvic floor muscles so they’re better able to prevent the outflow of urine when abdominal pressure threatens to cause stress incontinence. For instructions on how to do them, see inset below.
  • Get on a schedule. “Timed voiding,”or bladder training, involves making trips to the bathroom to empty your bladder on a set schedule (every two to three hours, for instance) while you’re awake.
  • Watch what you drink. Cutting back on or quitting alcoholic and caffeinated or carbonated beverages can help, but keep drinking water—dramatically reducing fluid intake can cause dehydration.
  • If you’re overweight, shed some pounds. A 2009 study in The New England Journal of Medicine found that obese women with UI who were enrolled in an intensive weight-loss program reduced weekly incontinence episodes by 47 percent (compared to 28 percent in a group of control subjects).
  • If you smoke, quit. Some studies have found that smokers tend to have more severe cases of UI, although no studies have evaluated quitting’s effect on UI.

How to Do Kegel Exercises

Pelvic floor muscle exercises, or Kegels, can help you strengthen the muscles involved in bladder control. They work best for stress incontinence. Here are the basic steps.

Medical therapy

If lifestyle changes and behavioral therapy aren’t enough to keep incontinence in check, medication may help. Some evidence suggests that combining behavioral therapy with medication is more effective than either approach alone.

Urge incontinence drugs. Six prescription drugs from a class called anticholinergics are approved for reducing bladder spasms in urge incontinence. However, many patients find these drugs hard to tolerate due to side effects such as dry mouth and constipation. Some users experience a loss of mental clarity, and research has linked long-term use of these medicines at high doses to dementia. An over-the-counter skin patch is also available and may have fewer side effects.

Another approved drug, mirabegron (Myrbetriq), which is from a class of drugs called beta-3 agonists, appears to work as well as the anticholinergics, without those drugs’ side effects, though it can raise blood pressure and increase heart rate, and you shouldn’t use it if you’re at risk for narrow angle-closure glaucoma.

Your doctor may suggest estrogen therapy, available in various forms such as vaginal creams and rings; studies suggest it offers moderate improvement of symptoms.

Stress incontinence drugs. There are no approved medications for stress incontinence, though some doctors prescribe duloxetine (Cymbalta, Irenka), which is approved for treating depression, chronic pain, and other conditions; evidence that it improves urinary symptoms is limited.

A vaginal pessary—a flexible ring inserted into the vagina—can reposition the urethra to reduce stress leakage but hasn’t been well studied. Other in-office therapies for stress incontinence include the injection of bulking agents that thicken the area around the urethra to help control urine leakage. The little research on this technique suggests it may offer only modest benefit.

Time for a procedure?

If medication is inadequate or intolerable, minimally invasive surgery may be an option. Midurethral sling procedures, the gold standard for stress incontinence, are commonly performed through a small vaginal incision. A sling made from synthetic mesh, animal or human donor tissue, or your own body tissue is positioned to support the urethra and help keep it closed under pressure. The procedure can be done on an outpatient basis. In the short term, the midurethral sling cures up to 98 percent of stress incontinence, according to a 2017 review in JAMA. Beyond five years, the sling has a success rate of 43 to 92 percent.

Surgical risks include bleeding, blood clots, and infection. Additional risks include injury to nearby organs, difficulty emptying the bladder, and a worsening of symptoms such as urine leakage and increased urination frequency. In less than 5 percent of cases, the synthetic material erodes, which can cause pain, bleeding, and discharge, requiring removal of the mesh.

Many women with UI say the condition leaves them unable to enjoy sexual intimacy. However, in a study published in February 2020 in Obstetrics & Gynecology, researchers followed 924 sexually active women (average age, 50) who underwent surgery for stress incontinence. The women reported improved sexual function within a year, an improvement that remained when measured again after two years.

For women with urge incontinence, procedures include electrical stimulation of the nerves that signal the need to urinate, which works about as well as anticholinergic drugs. Another option is Botox injections about every six months, which decrease muscle contractions. Botox can cause temporary urine retention, during which a catheter may be needed to void, and increases the risk of urinary tract infections.

This article first appeared in the May 2020 issue of UC Berkeley Health After 50.

Also see How Overactive Bladder Became a Disease.