Taking Back Control

By Kristin Kloberdanz

Deanna Bartosh likes her coffee. In fact, she's no sooner through the door of her favorite cafe in Antioch, Ill., than the workers greet her by name and ask whether she's ready for that cup. She laughs and says, no, she'll take it after lunch, and she's sure to remind the waiter midway through her meal, "I want that cup of coffee to go." The high school assistant and mother of three has only recently been able to indulge her passion for java, thanks to surgery last summer to repair a leaky bladder. The problem had plagued Bartosh, 61, ever since the birth of her first child 41 years ago but had grown noticeably worse in the past decade. "Every time I coughed or sneezed," she says, "I had to cross my legs to stop leaking or else die from embarrassment." Bartosh had to limit her liquid intake, and maxi pads became a wardrobe staple. After years of feeling ashamed, she finally saw a urologist. "I was looking for a way to make the quality of my life better."

Bartosh's problem is remarkably common but woefully underdiscussed. According to the American Urological Association, about 1 in 5 U.S. women over age 50 suffers from stress urinary incontinence (SUI), the tendency to leak urine when the bladder is stressed by running, jumping, sneezing, coughing or other activities. Urge incontinence, the sudden unbearable need to urinate, is far less common.

Childbearing is the biggest risk factor for SUI. Experts say approximately 1 of 3 women who have had a vaginal birth--even an uncomplicated one--will develop SUI at some point in their life. Giving birth to twins or bearing more than one child does not necessarily raise the risk because the damage has usually been done with the first child. "The big domino to fall is the first pregnancy," says Dr. Linda Brubaker, an expert in female pelvic medicine and reconstructive surgery at Loyola University in Chicago.

During labor the pelvic-floor muscles are often torn or strained, and nearby nerves can be harmed. Neuromuscular damage can also affect the urethral sphincter, the tiny knot at the base of the bladder that controls flow through the urethra. A woman who had labored but then had a caesarean section is at a slightly lower risk than if she had given birth vaginally. But preliminary studies suggest that SUI is rare in women who underwent scheduled Csections and never entered labor. That finding may be a factor in the rising rate of elective Csections.

Even young women can experience SUI after childbirth, but the problem rarely becomes chronic until much later, often around menopause. The loss of estrogen weakens muscle walls, but that only partly explains the timing. "There are a lot of injuries that happen during childbirth that women learn to compensate for," says Dr. Peggy Norton, chief of urogynecology and pelvic reconstructive surgery at the University of Utah. As a woman grows older, Norton explains, her body's means of compensating for the damage may give way. Her muscles may weaken, her reflexes may not be so sharp, or maybe she has gained some weight. All those factors can contribute to SUI years after the initial injury. Other risk factors include obesity, smoking, a pelvic fracture and severe bouts of coughing or constipation.

Whatever the cause of SUI, shame is a common side effect, and it often stops women from seeking treatment. Brubaker guesses that 90% of her patients wait years before coming to see her. "They think this doesn't happen to anybody else but them," she says.

Jane Lynch, 52, struggled along for years before seeking help. A resident of Naperville, Ill., she had to give up aerobics classes and going for walks because she would soak her pants every time. For the past two years, she says, it happened three or four times a day. "It was a miserable, miserable feeling," says Lynch, who was finally helped by surgery last year.

Remedies for SUI have improved in recent years. Today 90% of women who seek help find relief, and new treatments are on the way. Although there is no drug available in the U.S. for SUI (those "gotta go" TV ads are for Detrol, which curbs urge incontinence), duloxetine has done well in trials, and the U.S. Food and Drug Administration is expected to approve it within a year. It works by strengthening the urethral sphincter's contractions.

In the meantime, patients are usually given several options. The first line of treatment may be simple changes in behavior--losing weight, reducing intake of liquids or cutting back on irritants like caffeine, alcohol and cigarettes. If the patient's pelvic floor is weak, she will need to learn how to train her muscles with Kegel exercises--pelvic contractions that are commonly taught to prevent SUI after childbirth but that can also help restore control. Dr. Norton likens the urethra to a garden hose and the pelvic floor to the ground beneath it. When a cough comes along, it's like someone stepping on the hose. Having a strong platform beneath it--a sidewalk as opposed to a soggy lawn--stops the flow. Kegel contractions strengthen the platform but must be done correctly to work. Good instructions can be found online at www.nlm .nih gov/medlineplus/ency/article/003975.htm

Biofeedback techniques can help women isolate and work the pelvic muscles. A study published last July in the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION showed that biofeedback-assisted behavioral training reduces episodes of SUI almost 70%. Electrical stimulation also helps some women strengthen their pelvic muscles.

Another approach gaining popularity is collagen or fat injections, administered under local anesthesia by a urologist, to plump up tissues around the urethra. The body tends to absorb collagen, so the shots must be repeated every year or so.

Women looking for a quick and lasting remedy often choose surgery. Approximately 135,000 SUI surgeries are performed a year in the U.S., with a success rate of 75% to 95%. The two most common are the Burch procedure, which uses permanent stitches to support the bladder neck, and the sling procedure, which tightens the sphincter knot. Bartosh and Lynch say they are happy with their sling surgeries and report no leakage, though each had some initial complications afterward. "I feel so much better about myself," says Bartosh, gripping her coffee cup in the parking lot. "I've taken ownership of my body again."