Urinary incontinence is an awkward thing to talk about. It's an even more awkward thing to live with.
To prevent an accident, women who suffer from it stop doing things they love, such as running or playing sports. Some stop drinking the water they need to live a healthful life. Some are even nervous about leaving the house.
"There's a lot of shame, a lot of embarrassment," says Esther Dolowich, a physical therapist who specializes in pelvic floor dysfunction at Alta Bates Summit Medical Center in Oakland, Calif. "Somehow they feel that they are damaged goods. They are not OK."
When just a sneeze or a cough can bring on unintentional wetting, so-called stress urinary incontinence is an embarrassing condition that affects 15 million women, according to the National Association for Continence. Women are often hesitant to bring up the issue during doctor visits but, experts say, if they do, there are several options for treating the problem.
Urinary incontinence comes in a few forms for women, but the most common is stress urinary incontinence (SUI), the loss of urine when pressure is exerted on the bladder by sneezing, laughing, lifting or exercising. It's the type you see actress Whoopi Goldberg talking about in those TV commercials.
While it's widely believed that incontinence only happens to seniors, stress incontinence is also common in women in their 20s and 30s after childbirth and women in perimenopausal stages, the 40s and 50s.
Although anyone can experience SUI, it is commonly caused by natural childbirth. And, according to a Canadian study, it can increase risk of postpartum depression for new mothers. The probability of SUI increases when women have more than one child. This is because a vaginal delivery can weaken the muscles needed for bladder control and can damage bladder nerves. Often, delivery can lead to a dropped, or prolapsed, pelvic floor. The bladder and other organs are simply not in the same position they were in before the birth.
"Fifty percent of women who have had children have some degree of prolapse," says Dr. Tom Margolis, a urogynecologist with the Bay Area Center for Pelvic Surgery with several locations in the South Bay and on the Peninsula. "It's hardly possible that a woman can deliver a baby and not have some effect."
While some women choose to wear pads daily to take care of the issue, the Mayo Clinic advises women to seek a doctor's advice if urinary incontinence affects her day-to-day activities.
That's what Susie, a 34-year-old mother of two from Oakland, did after wearing pads for a while. She suffers from stress incontinence, a problem that started after she had her children.
"I noticed when I coughed or laughed or if I was reaching for something I had some leakage," says Susie, who preferred her last name be withheld to protect her privacy. "I had to start wearing pads. I was concerned about going out and worried about what might happen if I had a big accident."
So Susie stopped going out as much as she used to. She was reluctant to talk about it with her doctor, so she just lived with the problem. When she finally brought it up, her doctor suggested physical therapy to help control it.
"(After physical therapy) I felt more comfortable going out," she says. "I didn't feel like my life had to revolve around if there was a bathroom around or not."
Learning about urinary incontinence and the muscles near the bladder are initial steps a woman can take to help prevent accidents, Dolowich says.
"So many women improve significantly without surgery, just with education and exercise," she says. "Mindfulness, education, exercise and just paying attention can help."
In a perfect world, Dolowich adds, women would be taught at a high school level about their pelvic floor muscles and how Kegel exercises can help keep them strong. The proper way to do Kegel exercises is to imagine that you're trying to stop urine flow. You squeeze the muscles you would use to stop urinating. Dolowich says you should not attempt to do Kegels while actually urinating as it can disrupt a normal voiding reflex.
"It can take time to build the muscles, eight to 12 weeks, although a decrease in symptoms can be experienced before that time simply by an increased awareness of using these muscles at opportune times," she says. It is important to relax the muscles as well, she adds. Keeping them tight all the time will cause muscle fatigue and can exacerbate the problem.
Sometimes, women don't know which muscles they are activating when they attempt Kegel exercises, Dolowich says, and often times they are doing them incorrectly. They can benefit from working with a physical therapist who specializes in pelvic floor dysfunction so that the correct muscles can be identified, sometimes by using biofeedback tools, and correct contraction can be performed.
Once the Kegel muscles are strengthened, women can prevent accidents by engaging those muscles during times that they typically may lose urine-sneezing, coughing, laughing or lifting heavy items.
When education and physical therapy don't work, some women turn to surgery. The two most common are sling procedures and the Burch procedure, a bladder neck suspension surgery.
Dr. Judson Brandeis, a urologist with Pacific Urology in Concord, Calif., performs the sling procedure. He says all women should practice mindfulness and Kegel exercises postpartum. If those exercises and nonmedical interventions fail, a sling procedure can be an answer.
"It adds an extra layer of strength and compression of the urethra," which helps control urine flow, Brandeis says. He performs sling procedures on soccer players and Taekwondo experts, runners and athletes, many of whom have stopped doing their favorite things for fear of wetting themselves. Brandeis says women shouldn't have the sling procedure done while they're still trying to have children, but once they feel their family is complete, stress urinary incontinence can be addressed with a sling, and a person's normal routine usually can be resumed.
The sling is a mesh support that creates a sort of hammock around the bladder neck and the urethra and helps keep it closed when a woman coughs or sneezes. It is inserted into the body in an outpatient procedure that usually takes about 20 minutes. Women can go back to work within days and exercise within a month or so.
There have been many complications with the sling procedure since it was first introduced nearly 20 years ago, leading to a black box warning for doctors because of the risk. Brandeis says the current generation of slings use a synthetic polypropylene material which is much safer than older models.
Margolis of Bay Area Center for Pelvic Surgery says the gold standard for stress incontinence issues is the Burch procedure, which he performs about 10 times a week. Although Margolis does perform sling procedures, he says there are fewer complications with the Burch procedure, which requires four incisions and lifts up the bladder so it is closer to its original location.
Margolis, a longtime activist for safe incontinence treatments, warns that whichever surgical procedure a woman chooses to undertake, she should first research her provider before agreeing to the work. Many doctors will perform a sling procedure, but some aren't as well-trained to do it, he says.
"Avoid anyone who doesn't do it for a living," he says. "I don't think you can stay adequately trained on any surgical procedure if you aren't doing it on at least a weekly basis."
Susie, the mother of two, says physical therapy resolved her bladder problems in 2008. Now that they've returned after a bad fall, she is returning to physical therapy to help again.
"I am just not quite ready to do surgery yet," she says. "I am scared of surgery, and I'd like to see if I can manage without it."
Women should know, physical therapist Dolowich says, they are not the only ones suffering from this problem, though it might seem like it.
"It's really easy to project that everyone else in the world has a very intact system and that you are alone," she says. "That simply is not the case."