by Marcelle Pick, OB/GYN NP
Don’t just live with urinary incontinence — learn about the causes of incontinence and what you can do about it! Here are the topics discussed in this article:
- What is female urinary incontinence?
- The anatomy of the pelvis
- What type of bladder problem is it?
- What causes incontinence in women?
- Urinary incontinence after hysterectomy
- Bladder problems after menopause
- The emotional connection
- Urinary incontinence treatment — what you can do
The other night I was at a charity event and a friend introduced me to a group of eight women whose ages ranged from 35 to 50. One of them asked me what I was working on and I decided to be frank and say I was putting the finishing touches on an article about urinary incontinence in women.
You should have heard the outcry! Each woman had a different story to tell. One had to leave her aerobics class after her shorts got soaked. Another abandoned a grocery cart full of food in the check-out line to sprint for the public bathroom. Another organized her day around easy access to the toilet.
Every woman in that group (some were mothers, others were not) had some experience of losing bladder control. Most seemed to think it was an inevitable part of aging — complete with the requisite adult diapers or incontinence surgery.
Stress incontinence and overactive bladder (OAB, also known as urge incontinence), or a mixture of both, are extraordinarily common — but nobody wants to talk about them. In the past, traditional medicine viewed incontinence as primarily a men’s issue. But in my experience nearly all women suffer at some point in their lives from some form of urinary incontinence. What’s more, our bladder control issues can suddenly leap from moderate (or nonexistent) to severe with the onset of menopause, and especially take women who have never experienced childbirth by surprise.
It’s high time we bring urinary incontinence out into the light and talk about it. Women are so conditioned to suffer in silence, but stoicism that leads us to keep our health concerns quiet is not good for our health. In fact, women rarely mention urinary incontinence in their annual visits with me. So I ask! Incontinence may not be entirely avoidable as we get older, but it is certainly treatable, and there are very effective alternative methods. Let’s discuss what can be done both to prevent and to find relief from female bladder problems.
A sudden urge to go, leaking urine, and frequent urination are all forms of urinary incontinence, which is generally defined as a lack of bladder control. While there are many causes, the most basic is a gradual weakening of the pelvic nerves, organs and smooth muscles that are meant to work together to control urination.
The bladder itself is a sac that stores urine from your kidneys. When it’s full, pelvic nerves send a signal to the brain that you have to “go.” Your pelvic muscles, especially the sphincter of the urethra, clench, and “hold it” until you get to the bathroom. Once you’re there and safe, your brain tells the sphincter muscles to relax and your bladder empties.
Believe it or not, the muscle anatomy “down there” is still not completely understood by modern medicine. We do know it’s an intricate and amazing arrangement of dozens of muscles which keeps things in and lets them out as necessary. Naturally, the female pelvic floor is much more complex than the male pelvic floor because women have babies.
But a lot can change in the course of a lifetime. Inner pelvic muscles stretch and atrophy with age, pregnancy, gravity and trauma. Muscles can lose their elasticity with lack of use and loss of estrogen. Organs actually move around, often pressing on the bladder itself. In some cases the bladder or urethra may become damaged or chronically inflamed and malfunction. Scarring from surgery, injury or infection may disrupt the natural alignment of the organs inside the pelvic area.
And when you think about it, which of us doesn’t experience several of these factors over time?
You may have noticed the anatomical chart in your healthcare provider’s office of a woman’s internal organs. In that image, all of our parts are stacked neatly and well-supported within cushioning bands of smooth muscle. The vagina and the uterus nestle snugly between the urethra and bladder in front and the rectum and colon just behind.
There are several important ideas I want you to grasp from this picture to help you understand the help we have to offer for urinary incontinence:
- This elegant anatomy relies on the strength and tone of our pelvic muscles and ligaments, particularly the pelvic floor and perineum, to keep everything in its proper place.
- There is a lot of complexity in a small area — where our urinary tract, our reproductive tract, and our intestinal tract all converge. Changes in one of these systems can and do affect another.
- The bladder — and all the pelvic tissues and organs — are exposed to so many adverse developments in this picture, from posture to digestive problems, and some number of those adverse developments are inevitable as we get older.
Before we talk about how to relieve incontinence (sorry for the pun, but we have to keep our sense of humor!), let’s explore the different types of incontinence that women experience.
Stress urinary incontinence (SUI), also called light bladder leakage (LBL), is related to the weakening of the pelvic floor resulting in pressure (or stress) on an otherwise fully functioning bladder. One minute you’re laughing, sneezing or coughing, the next moment your underwear is wet. I know very few women who have not experienced some degree of stress incontinence at some point or another. Exercise (particularly jumping), orgasm, and even hearing running water can trigger it — often with greater regularity after menopause. It’s true that pregnancy and childbirth and pregnancy are frequently to blame for stress incontinence, but we also see a lot of women with stress incontinence at our practice who have never borne children.
Urge incontinence (UI) or overactive bladder (OAB) is a sudden, uncontrollable need to go, even if you just went ten minutes ago. It’s a result of uncontrolled contractions of the bladder muscle (called the detrusor) caused by a disruption in communication between the bladder and the brain. This happens due to inflammation of the bladder lining, infection, injury, natural atrophy that comes with age, or other reasons. Waking up once to several times at night to pee, called nocturia, is a common OAB complaint, as is accidental wetting due to an unstoppable urge to void. Sometimes overactive bladder is the result of overflow incontinence (see below).
Prescription medications for urge incontinence can either relax the detrusor muscle (e.g., Sanctura) or block the nerve impulses that prompt the bladder to contract (e.g., Detrol), which can be helpful for OAB, but they do not relieve symptoms of stress incontinence. They can also cause many side effects, including dry mouth, constipation, headache, blurred vision and dizziness, to name a few.
Many of our patients come to our medical clinic with a combination of both stress and urge incontinence, which is classified as mixed incontinence.
Overflow incontinence occurs when you can’t evacuate all the urine in your bladder because muscle tone is weak or you have a blockage. Symptoms of overflow incontinence include dribbling, urgency, hesitancy, straining, a weak urine stream or low urine production even though your bladder feels full. It’s more common in men, but overflow incontinence occurs in a significant number of women as well.
Once you and your healthcare provider have a better idea of what type of urinary incontinence you’re experiencing, you will have a better chance at getting to the root causes and deciding on the best form of treatment.
Sometimes the smooth muscle of the vaginal wall or the perineum overstretches and herniates, allowing the bladder or urethra to balloon through the weakened muscle. This herniation creates a pocket in the vagina known as a cystocele or urethrocele, which makes it difficult to fully empty the bladder or stretches the opening of the urethra, causing stress incontinence. You can usually feel a cystocele or urethrocele as a smallish, smooth bulge in the anterior (front) or side wall of your vagina. Overstraining, childbirth, and injury are the most common causes of cystoceles and urethroceles prior to menopause. After menopause, the natural thinning of the muscles is the more common culprit.
Chronic infection, surgery, medications (including synthetic HRT), radiation, adhesions, and disease are other factors that affect bladder function and the architecture of the muscles and nerves in the pelvis — and they can all contribute to issues with incontinence.
You are more likely to develop urinary incontinence if you have had significant trauma to the pelvis, spine or bladder, surgery, a disability or impaired mobility (which can make it hard to get to the bathroom). We often see a connection between incontinence and a car accident that occurred years beforehand, especially when those accidents were followed by a change in posture or chronic pain. Stroke, Alzheimer’s, multiple sclerosis (MS), and other central nervous system conditions are also associated with urinary incontinence. Some medications can also cause a loss of bladder control.
Systemic yeast, local yeast infections, and food allergies also play a role in bladder infections and interstitial cystitis. And, as in all inflammatory conditions, our emotions play a role in fueling the fire. For more on this, see our articles on inflammation. Smoking, obesity, and chronic constipation (with straining) are additional proven risk factors for developing incontinence over time.
Now let’s spend a moment on the link between hysterectomy and urinary incontinence.
Hysterectomy increases the odds of incontinence for two main reasons: the design and support of the pelvis is permanently changed, and women often lose the muscle-toning effects of their natural sex hormones post hysterectomy, even if their ovaries have not been removed.
A radical hysterectomy can cause extensive scarring that disrupts your inner musculature and nerves. If at all possible, we recommend having the least invasive hysterectomy available and keeping the ovaries intact. Many surgeons are now capable of performing a laparoscopic hysterectomy, which involves far less damage, or a modified procedure to ablate the uterine lining or embolize the arteries to the uterus without hysterectomy.
Keeping your ovaries is important when it comes to incontinence because of the beneficial effects of estrogen on the muscles of the bladder, bladder lining, and urethra, and on the connective tissues within the pelvis. Even so, in over half the cases, women who keep their ovaries still suffer some loss of ovarian function after hysterectomy, with negative effects on their hormonal balance. For more information, see our article on hysterectomy and hormones.
Studies also show that synthetic hormone replacement therapy increases a woman’s risk for stress incontinence, and we don’t recommend synthetic HRT in any form but prefer to administer bioidentical hormones transdermally or via lozenges. Topical bioidentical estrogen clearly helps promote a natural elasticity and suppleness in the pelvic floor. We’ve seen patients with UI respond extremely well to bioidentical estrogen cream applied directly to the vaginal wall and particularly the area near the urethra.
As if the hot flashes and mood swings weren’t enough, many of us going through menopause start experiencing more episodes of urinary incontinence. A decrease in estrogen initiates a thinning and weakening of the pelvic muscles and connective tissue — our house just starts to sag a little.
The relationship between bladder control and hormonal balance becomes increasingly important as we get older and transition through menopause. Some of us have been keeping an eye on the bathroom all along the way, but what about those women who never had an awkward leaky moment until their 40’s or 50’s?
We’re now seeing more ads for pharmaceuticals directed at female incontinence (somebody finally noticed!). But, as usual, they only address the most obvious symptoms and do nothing to treat the underlying loss of muscle tone. Most of the drugs available act on the muscle spasms related to overactive bladder, but do not treat stress incontinence. What’s more, they can cause other bothersome side effects.
As with any drug or hormone, you need to weigh the long-term risks against the potential benefits before taking a pill that could do serious long-term damage to your health. Of course, we recommend you try the most natural steps first, and resort to drugs only if necessary to get symptom relief.
After menopause, women are more prone to bladder infection, chronic urinary tract infection (UTI) or cystitis. As the urethral muscle loses strength and elasticity due to loss of estrogen, pockets of bacteria can flourish. Taking an antibiotic — nowadays there’s a one-day massive dose — is usually adequate, but in some cases inflammation takes hold and damages the lining of the bladder.
This condition, called interstitial cystitis (IC), is a growing concern in women’s health that warrants an entire article of its own. It’s an inflammatory condition that manifests with all the symptoms of a urinary tract infection even when no bacteria are present. It would not surprise me to find in the future that estrogen imbalance is somehow implicated in the escalating rates of interstitial cystitis that I’m seeing.
In Chinese medicine, the bladder is related to issues of anger and control — there’s ancient wisdom at work when we say we’re “pissed off.”
In yoga, the root lock — or mula bunda in Sanskrit — is located at the base of the perineum. It is one of the three major body locks that control our inner life force, or kundalini. (Note that this inner life force is considered to be female!) It is closely related to the earth and the force that connects all living things. Lifting the mula bunda creates stability and energy within the body, channels our life force up through the chakras, and imbues our bodies with a sense of weightlessness. You can access this life force with kundalini yoga postures and Kegel exercises, as discussed below.
Incontinence can sometimes be a physical manifestation of some deep-seated fear or worry that weighs us down. It’s often related to anxiety or anger about losing control. Occasionally, sporadic episodes of incontinence will occur during a particularly stressful — or “out-of-control” — phase of your life. Pay attention to your feelings and see if you notice any patterns.
Bladder issues are like so many health-related concerns — the sooner you attend to them the easier they are to treat. So here’s what you can do:
See your healthcare provider. If you are noticing any urine leakage or an increased frequency of urination, the first step is to get checked out by your healthcare practitioner. Depending upon the situation, you may find it useful to consult further with a gynecologist, urogynecologist, or urologist.
When we see women for bladder problems, we first try to figure out what kind of urinary incontinence they are dealing with. Most often this is some form of mixed incontinence that can be treated through alternative therapies.
Pelvic floor exercises. In cultures where women squat to do their work, there is a much lower incidence of incontinence. Most women don’t do much in the way of that kind of labor anymore — but we’ve got Kegel exercises! Incontinence can often be arrested or reversed with Kegel exercises alone. Named after an American ob/gyn, these simple exercises are really an adaptation of the “root lock” of kundalini yoga without the trappings. You can do them anywhere, anytime — and you should.
To do a Kegel, imagine that you are trying to stop yourself from urinating. Practice both short and long Kegels. You can even do an anticipatory Kegel before you sneeze or cough and prevent leakage! For more information on Kegel exercises for urinary incontinence, visit the University of Iowa Hospital and Clinics’ website.
A wonderful added benefit of Kegels is that the increased muscle tone can increase sexual pleasure in both sensation and orgasm. Male partners are happier too!
Sometimes women have trouble identifying the muscles that control the bladder and get frustrated attempting Kegels. This can be a natural result of conditioning the brain to ignore bladder stimulation. How many of us are too busy to go to the bathroom when we feel the urge, then “forget” we had to go. Over time, it’s possible that our brain just stops paying attention and we disconnect. It can take some work to get those pathways talking again.
If Kegel exercises don’t seem to be working well for you, you can try insertable cones or balls (available through your doctor or on the internet) to help you train your PC (pubococcygeal) muscle. Biofeedback practitioners use electronic monitors inside the vagina to help women learn how to identify and tone muscles related to the bladder. Both tools can be very effective.
Any kind of physical exercise that engages your core will help strengthen your pelvic muscles, but Pilates and yoga in particular are great inner toners. Both focus on building a firm core or root. They also use deep breathing and mindful movement to reconnect the brain to the body.
Acupuncture is another method that has provided symptomic relief for some women. It helps tone muscle and increase blood flow to the bladder. It can boost the immune system, soothe inflammation, and restore balance to the hormones.
Pelvic physical therapy (PPT) is sometimes effective in difficult cases. Practitioners use several diagnostic tools, including sonograms, physical exams and lower back screenings to evaluate the cause of incontinence. Treatment may include external and internal pelvic floor massage, relaxation training, biofeedback, strengthening, bladder retraining, and home exercises. This is especially useful when patients have adhesions or physical anomalies due to radiation treatment, injury or surgery. Many women who undergo PPT report increased libido and enjoyment of sex in addition to better bladder control.
Nutrition is vital to restoring a healthy balance to your endocrine and immune system, which in turn is important for maintaining muscle tone and preventing infection. Eating a diet of whole foods with plenty of fruits, vegetables, protein and some whole grains will promote adequate nutrition and help level out your hormones. Be sure to take a robust multivitamin/multimineral formula to support your body. And try supplements with cranberry extract — just be sure they don’t have added sugar.
Allergies may exacerbate an overactive bladder. If you think you may have food allergies or sensitivities, we recommend trying an elimination diet (avoiding a suspicious food for two weeks, then re-introducing it for a day or two).
Drink plenty of water and herbal tea. Flushing your urinary tract regularly will help evacuate bacteria. Cranberry juice and extracts can help prevent urinary tract infections by changing the pH of the bladder, but again, be sure you choose one with no added sugars. (Excess simple carbohydrates in the diet only encourage UTI’s). If you are getting up in the middle of the night to urinate, stop drinking a few hours before bed.
Internal or surgical methods. If you’ve tried everything and you still can’t go out for an evening without worrying, you may want to consider a form of internal intervention. If urinary incontinence is keeping you from fully enjoying your work, love life, hobbies and pursuits, then fitted internal devices or surgical interventions are a reasonable next step.
Fitted pessaries, sometimes referred to as prolapse pessaries, are removable umbrella-like support rings that can help lift your pelvic organs up off your bladder. A pessary can be a great non-invasive choice for a woman with a cystocele or uterine prolapse.
New techniques like bladder laparoscopy and bladder slings can be helpful for treating severe stress incontinence in some women. Currently the most common procedures are known as the Burch colposuspension technique and the fascial sling. In the past, bladder suspension surgeries had a useful life of about four years. In the Burch, the urethra and bladder are secured with sutures to the pelvic wall. The new bladder slings use life-like materials that move with the body and act like real muscle.
Unfortunately, however, a study published recently in the New England Journal of Medicine suggests that neither of these surgical procedure offers terrific results for the women who have them. Known as the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr), the fascial sling was compared with the Burch colposuspension technique for treating stress urinary incontinence — the type of leaking that can occur when we run, laugh, sneeze, cough, or lift heavy objects. A mere two years following surgery, only 47% of the sling patients and 38% of the Burch suspension patients experienced good resolution of their stress urinary incontinence. Even so, the better results of the sling appeared to be offset by higher rates of UTI’s, problems with voiding, and even urge incontinence.
As with any surgery, we recommend getting as much information as possible and discussing your options with a few practitioners. More progressive doctors are using the latest technology to re-engineer a leaky bladder without excessive trauma and scarring. There are now gynecologists who specialize in urology (urogynecologists), and more women are going into urological surgery (formerly an exclusively male specialty). It’s safe to say that the more experience a surgeon has with a procedure, the more likely it is that you will experience the results you are looking for.
Emotional work. Understanding our hidden fears and anger or reluctance to “let go” can be a powerful remedy in dealing with incontinence. Many women have found relief with the Feldenkrais method — a mind-body technique that can help heal physical conditions through the release of emotional blockages with movement.
Because the brain and the bladder are intimately connected, it only makes sense to approach incontinence on both fronts.
Don’t just live with incontinence
I know there isn’t an easy remedy for urinary incontinence. Gravity, aging and loss of estrogen are pervasive. But like so many problems with our bodies, let’s focus on what we can control — because that’s how we’ll find solutions. I feel for every woman whose life is compromised by urinary incontinence. With a willingness to talk about it and experiment with changes, we so often see great improvement.