A year after the birth of her second child, Kathleen (who asked that her last name not be published) developed stress incontinence -- a type of urinary incontinence that can make you leak urine when you cough, sneeze, laugh, or take part in physical activities.
“I was only in my 30s,” Kathleen says. "And I was leaking up to five tablespoons of urine during any activity. I had children in preschool and was dealing with this mess. I thought, ‘I can’t live like this.’"
There's great news for the millions of people like Kathleen, who develop urinary incontinence: "They don’t have to live with it,” says Kevin Stepp, MD, director of urogynecology and minimally invasive gynecology surgery at the Carolinas Medical Center Women’s Institute in Charlotte, NC. “It’s very common and there are a lot of options that are well tolerated, low risk, and non-surgical or minimally invasive.”
Yet many people do live with urinary incontinence -- and as a result, may withdraw socially or become depressed -- because they never get diagnosed or treated for it. Why? Many are embarrassed to bring it up with their doctors, especially if it occurs during sex. Others believe that it's just a part of aging, and there's nothing to be done.
Knowing what kind of information your doctor needs from you and what you need from your doctor can make it easier to talk about urinary incontinence. Kathleen's experience, along with advice from doctors who treat the condition, may help you start talking -- and start getting relief.
Women and Urinary Incontinence
Twice as many women as men develop urinary incontinence. Two common types are stress incontinence and urge incontinence from overactive bladder (OAB).
It's important to observe as much as possible about your urinary incontinence so you and your doctor can develop the right treatment for you. For example, when you get an intense urge to pee, are you unable to make it to the toilet without urinating -- a sign of urge incontinence? Or do you leak small amounts of urine -- a symptom of stress incontinence?
Stress incontinence is the most common type of incontinence in young and middle-aged women. It can be caused by changes that occur during pregnancy, childbirth, or menopause. In Kathleen's case, the pelvic floor muscles, which support the bladder, had torn during her first delivery. Before the birth of her second child, she religiously did Kegel exercises to strengthen the muscles, which help hold in urine. But the baby was close to 10 pounds and the delivery took a further toll.
Overactive bladder happens when inappropriate nerve signals are sent to the bladder, creating the “gotta go” sensation, although the bladder may not be full or it is an inappropriate time. This can lead to involuntary loss of urine. OAB can be the result of nerve or muscle damage, medical conditions, even a reaction to medications.
“Patients will often have both,” Stepp says. “If a patient has 'urgency,' they may have mild bladder contractions that create the urgency, but don’t actually cause leakage because their muscles are strong enough to keep it in. Sometimes they have severe bladder contractions, and not even the best muscles can stop that. Or they may have a weak muscle from some stress incontinence and mild urgency or bladder contractions causing them to leak with both. That’s where fixing one may fix another.”
Urinary Incontinence: Starting the Conversation
Since discussing urinary incontinence is usually the biggest hurdle for people, some doctors have found ways to integrate it into the conversation.
“I’ve made asking whether women are leaking urine a part of my routine history that’s taken when they come in,” says Greg Kitagawa, MD, assistant professor in the department of reproductive biology at Case Western Reserve University and an ob-gyn at MetroHealth Medical Center in Cleveland. “That way I’ve already opened the door for them to discuss these things with me.” As a result, Kitagawa says, the topic is less threatening and patients are more open to talking about it.
So when should you talk about it with your doctor? Stepp says there's no amount of leaking that is too little to discuss. “A woman should speak to her doctor if it bothers her," he tells WebMD.
Evaluating Urinary Incontinence
Once you broach the subject, your doctor will usually ask questions to help determine what kind of incontinence you may have. Tests may also be needed to rule out potential causes contributing to incontinence like infections, diabetes, or other medical issues.
Sometimes doctors ask people to track their urination pattern for a few days or more. This "bladder diary" can include information such as how much liquid you drink each day, any drugs you take, and symptoms such as straining that may occur with incontinence, as well as when and how often it happens. You can also keep a bladder diary before you see a doctor so you are prepared to answer common questions.
Stepp says it helps doctors to know how a woman has tried to treat the symptoms -- and what treatments she's willing to try. “Many women go online for information and try to do Kegels,” he says. “I find out what they’ve tried and where they’re looking to go. Are they saying, 'I want help, but I don’t want surgery'? Or are they saying, 'I’ve been dealing with this for so long. Just take me to the O.R. and fix it'?”
Letting Your Doctor Know How You Feel
Kathleen knew she wanted to get help for her leaky bladder. "Once you have a problem with incontinence, it becomes all you think about," she says. "Even something as simple as going to a store takes planning.” She sought help early on, learned about her options, knew what she wanted to try first, and communicated her desires to her doctor.
Kathleen decided to have surgery to implant a urethral sling at Duke University Hospital in Durham, NC. Changes in the pelvic floor muscles can cause the bladder to move out of it's normal position and a sling helps hold it back in. She was pleased with the results.
Fourteen years later, however, she noticed symptoms of stress incontinence again. “I was just leaking a little,” she says. “But I knew about physical therapy and felt that if I worked on developing those muscles now, before it got really bad, I wouldn’t need to have surgery again.” She also wanted to avoid taking medications, if possible.
Her doctor referred her to a urogynecologist, a specialist in urinary and associated pelvic floor problems. “I told him I wanted to try physical therapy first, unless it was something I couldn’t do because of prior surgery or other issues," Kathleen says.
The urogynecologist’s exam turned up two issues adding to her stress incontinence -- a weak urethra and a prolapsed, or dropped, bladder. He advised trying intensive pelvic floor physical therapy, including Kegel exercises, and referred her for nine weeks of treatment.
“He said that at the end of that time, if they sign off and say I’m doing great, I can do my therapy at home,” Kathleen says. “But if not, he wants to see me and we’ll discuss surgical options.”
Lifestyle Changes That Can Make a Big Difference
When people are considering their treatment options, Kitegawa says, it’s important for doctors to make sure they have realistic expectations. “We know people want a ‘quick fix,’” he says. “That’s a possibility sometimes, but they need to know that physical therapy and lifestyle changes can have a much longer lasting impact.”
Your doctor may want you to start with these behavioral changes:
- Cut caffeine, alcohol, and nicotine. Stepp and Kitagawa say this is critical. “If you cut your caffeine intake in half, you’ll notice a difference,” Stepp says. “If you eliminate it completely you’ll notice more of a difference.” Stepp calls alcohol the "double whammy": “Not only is it an irritant, it also makes you pee more. It increases the volume in the bladder.” And he is adamant about eliminating nicotine. “If you want to tackle bladder symptoms, you have to stop smoking,” Stepp says. “Nicotine stimulates urgency.” And coughing associated with smoking aggravates stress incontinence.
- Bladder retraining. In addition to eliminating caffeine, Kitagawa suggests restricting fluids prior to going to bed, if possible. "Timed voiding" -- going to the bathroom at regularly timed intervals -- is one way of retraining your bladder.
- Kegel exercises. These can help strengthen the muscles that hold urine in.
“I would rather avoid medications if at all possible because they aren’t without their own side effects, including dry mouth and dry eye,” Kitagawa says. “That seems counterproductive.” When he does prescribe medications, he does so with the caveat that the person must quit caffeine, nicotine, and alcohol. “Those three will undo whatever the meds are trying to accomplish,” he says.
Whether solutions are achieved through lifestyle and behavioral changes, medication, surgery, or a combination of treatments, talking openly and honestly with your doctor can get you on the right road. “There is help available, and some of it is super easy," Stepp says. "Incontinence doesn’t have to control your life.”