Nine years ago, Lee Greenwood developed a problem that, she says, could have made her hide from the world.
Greenwood, a real estate agent, wet her pants while showing a home. It was the first of many accidents. "I had to do something about it," says Greenwood, 59, from Swarthmore, Pa. "I was not going to be a recluse."
Though Greenwood's problem is common -- 20% to 30% of women have it -- her attitude is not.
Fewer than half of women with incontinence seek treatment, says University of Pennsylvania nurse practitioner Diane Newman, who treated Greenwood. Some women are afraid to ask, she says, and others don't realize treatments are available.
"These patients are devastated," Newman says. "It's still such a hidden condition."
Greenwood tried a variety of strategies for 1 1/2 years -- including pills to ease bladder spasms, a special diet and even antidepressants. Nothing worked.
To give better guidance to doctors and patients, the National Institutes of Health in March published a new "state-of-the-science" statement, based on nearly 100 clinical trials and three comprehensive reviews, on non-surgical ways to treat incontinence.
Surgery vs. non-surgery
While surgery is effective for up to 90% of women, Newman says, it can be painful and increases the risk of side effects, such as bleeding. Some patients who have surgery develop new bladder problems, such as the need to urinate frequently, Newman says.
The most promising non-surgical approach -- physical therapy called pelvic floor muscle training -- can cure half of women with stress incontinence, in which urine leaks during activities such as sneezing or coughing, the report shows.
Through the training, which includes exercises called Kegels, patients strengthen muscles around the urethra that control urination, says Jean Wyman, report co-author and a nursing professor at the University of Minnesota. Unlike medication, the exercises have no harmful side effects and often can be taught by women's primary care providers, she says.
But isolating tiny internal muscles isn't easy for everyone, Wyman says. Only about half of women can do the exercises correctly on their own. The rest need additional help from physical therapists or nurses, Wyman says.
The report notes that the training works well when combined with biofeedback, which is especially helpful for women who have trouble isolating the correct muscles. Biofeedback sensors, attached to the pelvic floor, allow women to watch their muscles working on a computer monitor, helping them eventually learn to perform the exercises on their own, Wyman says.
The report shows that it's also helpful to learn "bladder training," in which women follow a schedule when visiting the bathroom, with the aim of eventually going less frequently,
Pelvic exercises also can prevent incontinence, says Robert Kane, a co-author of the March report and geriatrician and epidemiologist at the University of Minnesota School of Public Health.
He recommends the exercises for women who are at higher risk, such as those who leaked during pregnancy, who had a forceps delivery, a hysterectomy or other pelvic surgery. Although about 20% to 30% of pregnant or postpartum women experience incontinence, Kane says, about half of them improve on their own without treatment.
Although some pregnant women opt for Cesarean section for fear of damaging their pelvic floor, Kane says there's no solid evidence that C-sections prevent incontinence. The real risk, he says, appears to come from the strain of being pregnant, rather than the trauma of childbirth.
There's also no research to prove that incontinence is more common in those who have several children, compared with those who have only one.
The risk of incontinence increases with menopause. After age 40, other risk factors -- including diseases of aging such as diabetes -- contribute more to incontinence than pregnancy, Wyman says. By the time women are elderly, those who have had children are no more likely to suffer incontinence than others.
The report considers other ways to treat incontinence.
In a study called the Diabetes Prevention Program, overweight women who exercised and lost at least 7% of their weight reduced their risk of stress incontinence by 15% after a follow-up of three years, according to the NIH paper, published in Annals of Internal Medicine. Women who quit smoking are also less likely to leak, partly because they cough less, which reduces strain on their pelvic floor, Newman says.
And certain medications -- such as Detrol and Ditropan -- also can help. But all medications aren't alike. While estrogen patches and gels alleviate incontinence, the report notes that hormone pills make it worse. Kane says doctors aren't sure why.
Use of electrical stimulation
Greenwood finally solved her problem three months after Newman taught her to use electrical stimulation at home. Greenwood still uses the system, in which an internal sensor contracts the pelvic floor muscles for her, half an hour a day. Although the technique worked for her, the NIH report notes there's no evidence that it benefits women in general.
Greenwood says she no longer lives in fear of accidents. She still uses a patch, which provides Detrol through the skin, and wears pads as insurance. She also does regular pelvic floor exercises.
Wyman says women shouldn't be afraid to seek help -- even if they've suffered for years.
"At any age," Wyman says, "it's never too late."
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