For the 25 million U.S. adults with urinary incontinence, a little leakage can carry a lot of shame. But many people don't do anything about it.
"Urinary incontinence is a very insidious process," said Dr. David Glazier, co-director of the pelvic floor center at Virginia Urology in Richmond, Va. "It occurs very slowly; (people) think it's a normal part of aging."
Increasingly, women are taking action. They are "more physically active, fit, and they're not going to tolerate wearing pads all the time," said Dr. Vivian Aguilar, a urogynecologist at Cleveland Clinic Florida who sees many incontinence patients in their 30s, 40s and 50s.
The most common types of incontinence among women are stress and urge incontinence. Pelvic organ prolapse can be a cause. Most women see improvement or cure through behavioral modification (losing weight, limiting caffeine, alcohol and artificial sweeteners) and Kegel exercises to strengthen the pelvic floor muscles, considered the frontline treatment for both types, said Dr. Margaret Roberts, attending physiatrist with the Rehabilitation Institute of Chicago. But a third of women don't do Kegels correctly, she said, and those frontline treatments don't work for everyone.
Here are other solutions, which depend on what type of incontinence a woman has, drawing from the expertise of Glazier, Aguilar and Roberts:
What it is: Leaking urine as a result of abdominal pressure, such as laughing, coughing, sneezing, running, jumping or having sex. It happens as the valve muscle around the urethra weakens and wears down with time, and commonly starts after childbirth, which stretches out the tissues that support the urethra and bladder. It is the most prevalent type of incontinence among women, affecting one-fourth of women over 17, and it becomes increasingly common with age.
Medication: There are no FDA-approved medications for stress incontinence. Duloxetine (Cymbalta), an antidepressant, is approved in the European Union for stress incontinence and is sometimes used off-label in the U.S., but it carries an FDA-issued black-box warning of suicide risks.
Bulking agents: Injecting collagen or carbon spheres into the tissue around the bladder neck and urethra helps close the bladder opening to reduce leakage. Over time, the body might eliminate the agents so you have to repeat injections.
Slings: A small ribbon of mesh, usually inserted through the vagina, is placed around the urethra to support it. This common outpatient surgical procedure, usually done under general anesthesia, has a 90 percent success rate, but it carries risks. The FDA in 2008 warned of serious complications with mesh used for stress incontinence and prolapse procedures, including infection and migration or erosion of the mesh into the vagina, potentially causing pain during intercourse. The procedure also can be performed using tissue from your own body.
Burch procedure: Through an incision in the abdomen, a surgeon pulls up the bladder and sutures it to ligaments behind the pubic bone, giving support to the urethra. It has a slightly lower success rate than a sling, but it has fewer side effects, according to a study published in the New England Journal of Medicine.
What it is: Having the sudden urge to urinate and not always making it to the toilet. While the causes aren't well understood, it happens when abnormal nerve signals cause bladder contractions when you're not ready and can be brought on by infection or nerve injuries, such as multiple sclerosis or stroke. It is associated with overactive bladder, which also includes urinary frequency (needing to urinate more than seven to 10 times per day), and nocturia (waking up at least twice a night to pee). Urge incontinence and overactive bladder affect one-fifth of adults older than 40 and are twice as frequent in women as in men.
Medication: Medications such as VESIcare, Ditropan and Toviaz help with overactive bladder symptoms by relaxing the bladder muscles.
Neuromodulation: Interstim is the brand name for a pacemaker-like device that is implanted under your skin, just above the buttocks, to deliver electric pulses that calm the bladder. You do a two-week trial before implantation to confirm it works before committing. Possible complications include discomfort and infection. Because it's metal, you can't have an MRI.
A less invasive option is peripheral nerve stimulation, wherein a doctor places a small needle in one of the nerves in the foot, next to the ankle bone, and sends an electric signal to the bladder nerves to calm down. You must do half-hour sessions once a week for 12 weeks, and then once a month after that. Unlike Interstim, it's not covered by most insurance.
Botox: The FDA in August approved Botox bladder injections to treat urinary incontinence in people with neurologic conditions such as spinal cord injury or multiple scerlosis. The effect lasts for up to 10 months, so you'll need repeat visits. Some people have trouble emptying their bladder afterward and must use a catheter.
Augmentation cystoplasty: The end-of-the-road treatment for overactive bladder, this involves cutting into the bladder to increase the capacity and decrease contractility. Afterward patients may have to catheterize themselves.
PELVIC ORGAN PROLAPSE
When childbirth, hysterectomy or other surgery weaken the muscles and tissues supporting the pelvic organs, a woman's bladder, uterus, bowel or rectum can shift from their normal positions and drop into the vagina. Stress incontinence can result, or the drooping organs can kink the urethra, causing urinary retention. POP affects as many as half of women who have given birth, but only 10 to 20 percent experience symptoms.
Pessary: A diaphragm-like device that you insert into the vagina to help keep the organs in place. You must remove and reinsert the pessary regularly for cleaning.
Surgical repair: Surgeons can fix prolapse as they would a hernia, pulling up and securing collapsed organs. When prolapse is accompanied by incontinence, they would install a sling during the same procedure. For women who have had several unsuccessful repairs, some doctors insert mesh through the vagina to hold up the sagging organs, but mesh has risks. In July, the FDA updated its warning on using mesh to correct prolapse, citing serious complications including mesh protruding through the vaginal wall and organ perforation during insertion. The greater risk does not come with greater clinical benefit, the FDA said, and removing the mesh may not be possible and may not resolve complications.
Learn more: National Association for Continence, nafc.org.