Urinary Incontinence: Don’t Suffer in Silence

Urinary incontinence (UI) can leave you fearing loss of bladder control every time you cough or laugh, or planning your days so 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 leave you depressed, interfere with sexual intimacy, and even increase your risk for falls (due to hasty trips to the toilet).

Yet only about one in four women with UI seeks or receives medical help, due to either embarrassment or the belief that UI is just a part of normal aging. That’s not the case, though, 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 Urinary incontinence, 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, according to a 2017 review in JAMA.

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 weaken.

What’s your type?

There are three main types of Urinary incontinence:

• 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 situations 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 more than once at night.
• Stress incontinence can make coughing or laughing—or sneezing, exercising, or lifting heavy objects—risky. Such actions 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 is 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 treatments, and specific exercises as first-line treatment for controlling Urinary incontinence. And for good reason: A review of 84 clinical trials published in Annals of Internal Medicine in 2019 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 of adopting approaches like the ones below:

• Learn Kegel exercises (see box below). Also known as pelvic floor muscle exercises, Kegel workouts strengthen the pelvic floor muscles that support the bladder.
• 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 study in the New England Journal of Medicine found that obese women with UI who lost weight 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.
• Perhaps acupuncture? A systematic review and meta-analysis of eight studies over the past decade involving middle-aged and elderly women in China with stress incontinence found that acupuncture was more effective in reducing urine leakage than other treatments, including medication and rehabilitation exercise. Acupuncture was also associated with improved subjective scores on a questionnaire evaluating the severity and impact of incontinence on quality of life. But more large, high-quality studies are needed to verify the results.

Medical therapy

If lifestyle changes and behavioral treatment aren’t enough to keep incontinence in check, medication and other medical approaches may help. Some evidence suggests that adding behavioral therapy to the mix is more effective than either approach alone.

For urge incontinence. Six prescription drugs from a class called anticholinergics are approved for reducing bladder spasms in urge incontinence. These drugs can be hard to tolerate, though, due to side effects such as dry mouth and constipation. Some users may experience difficulty concentrating, confusion, or other cognitive side effects, and research has linked long-term use of these drugs 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. Newer medications like mirabegron and vibegron have a more favorable side-effect profile.

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

For stress incontinence. There are no approved medications for stress incontinence. A vaginal pessary—a flexible ring inserted into the vagina—can reposition the urethra to reduce stress leakage, but it hasn’t been well studied. Other in-office treatments 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 surgery?

When all else fails, 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 used to support the urethra and help keep it closed under pressure. The procedure can be done on an outpatient basis. Slings tend to be quite effective long term, though some women may have recurrence of symptoms and choose to undergo retreatment.

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

A side benefit of surgery for stress incontinence is that it may improve sexual intimacy, something that many women with Urinary incontinence have difficulty with. A 2020 study in Obstetrics & Gynecology followed 924 sexually active women (average age, 50) who underwent surgery for stress incontinence. Improvements in sexual function were seen within a year and were still present at the two-year follow-up.

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. But Botox also can cause temporary urine retention, during which a catheter may be needed to void, and it increases the risk of urinary tract infections.