Although many are reluctant to talk about it, urinary incontinence is a struggle for women of all ages, from all walks of life. Many women experience involuntary loss of urine as they get older, but urinary incontinence should not be considered a normal part of aging. 

There are effective treatments available that can help prevent unintentional urine loss. At Yale Medicine's Pelvic Medicine & Continence Center, our clinicians use the latest diagnostic tools to determine which treatment is appropriate for you. 

"Anyone who has had two babies and is 45 or older has likely had an experience with urinary incontinence," says Oz Harmanli, MD, chief of Yale Medicine Urogynecology & Pelvic Reconstructive Surgery and a professor of obstetrics and gynecology and reproductive sciences at Yale School of Medicine

"They may not be at a point where they need to seek help, but when they get into their 50s, it often becomes a more common problem. We have a 90-percent treatment success rate when urinary incontinence comes from physical exertion, or stress."

Female incontinence is the loss of bladder control in women. It is not uncommon to lose urine during pregnancy or with urinary tract infections temporarily. There are many reasons you might develop urinary incontinence as a chronic problem. The most common causes are pelvic floor trauma with childbirth, menopause, hysterectomy, obesity, cognitive impairment, chronic cough and constipation.

There are three types of female incontinence:

• Urge incontinence: Women with urge incontinence feel the need to urinate frequently. They experience leakage of urine during times associated with this urge. 
• Stress incontinence: Women with stress incontinence, also known as physical or exertion incontinence, may experience urine leakage, especially when coughing, laughing, exercising or sneezing.
• Mixed incontinence: Many women experience a combination of stress incontinence and urge incontinence.

Female incontinence is very common, but there are a few factors that may increase the risk. They include:

• Age: With age, the muscles in the bladder and surrounding areas begin to weaken, which may lead to incontinence.
• Pregnancy and vaginal delivery: A vaginal delivery can strain or damage the muscles of the pelvic floor, leading to future problems with incontinence. However, an uncomplicated vaginal delivery should not typically cause urinary incontinence, Dr. Harmanli says.
• Being overweight: Patients who carry extra weight are also putting increased strain on the bladder and its surrounding muscles.

Involuntary loss of urine or leakage can be characterized by an overactive urge to urinate or an inability to control urination while laughing, sneezing or coughing.

Because there are many different factors that can contribute to urinary incontinence, a doctor will first take a take a detailed medical history and conduct a physical exam. A qualified nurse practitioner will also perform a test for involuntary urine loss by inserting a small catheter (tube) to empty the bladder completely and then fill it with water. With a bladder full of water, you will be asked to cough and bear down, and the nurse will measure the amount of water that escapes

This evaluation will help determine if the condition is severe enough to warrant a urodynamic study, which measures the activity of the bladder as it fills and empties. This will help determine the cause and severity of the problem and guide the best treatment.

We offer surgical and nonsurgical urinary incontinence treatments. Since women who experience urinary incontinence might also suffer from pelvic organ prolapse or other pelvic floor issues, we work with a team that includes surgeons, urogynecologists, physical therapists and any other members of her care team to determine the optimal treatment plan.

Nonsurgical options

Depending on the type of urinary incontinence, there are several nonsurgical options available. The most effective ones include:

• Kegel exercises strengthen the pelvic floor. "Pelvic floor exercises should be part of a woman’s routine just like brushing your teeth," Dr. Harmanli says. "You need them for the health of your pelvic floor, even if you don’t experience any symptoms or even if you never had children. The best part, he says, is that you don't have to go to the gym and can do them sitting at your desk or in your car. "Your medical provider can give you some feedback on how you are doing them at your next exam. It’s the same thing you do when you have a full bladder and you don’t want to leak. You contract for five to 10 seconds and then let go for five to 10 seconds and do a set of 10 to 15. Three sets a day at least is ideal." 

• Timed voiding (going to the bathroom on a regular basis, for instance, every two hours even when there is no feeling of urge). Dr. Harmanli also suggests watching your fluids, the amount and the content. Coffee, tea, soda are all stimulants. It may be OK to drink a cup of coffee in the morning if you depend on it, he says, but maybe you want to avoid having two in a row.

• Weight loss and exercise. A doctor may also prescribe medication to relax bladder spasms or urges, or inject collagen to increase the resistance of the urethra. Botox injections are also sometimes used to relax the bladder.

Surgical options

If you do not respond to non-surgical treatment or you have very severe incontinence, surgical management should be considered. While pelvic floor exercises and behavioral and lifestyle changes often work best for urge incontinence, stress incontinence responds extremely well to surgery, Dr. Harmanli says.

The leading surgical method for stress incontinence is the “sling” procedure. This involves placing a thin, small sling made of synthetic material or mesh beneath the urethra, the tube which drains the bladder outside. This minimally invasive surgery can be done as same-day surgery. 

"It takes less than 30 minutes and most women can go back to work in a few days and can resume intercourse in three weeks, Dr. Harmanli says. "You can squeeze it into your busy life, and it is proven to be safe and effective. This is one of the best studied procedures that we do."

Incontinence is a difficult subject for patients to talk about. Here at Yale Medicine, we know the best conversations start with listening. We guide you towards treatments that best match your goals and lifestyle. 

We are experts in the latest non-surgical and surgical techniques, and we have an established Urogynecology fellowship program. "We are training the future urogynecologists and that makes us stay sharp," Dr. Harmanli says. "Plus, at Yale, we are surrounded by other specialists such as urologists, gynecologists, and colorectal surgeons with whom we can coordinate your care." 

At Yale Medicine Urogynecology & Reconstructive Pelvic Surgery, you will work with not only doctors but physical therapists and our nurse practitioner Cherrilyn Richmond, who will coach you through pelvic floor exercises.

Furthermore, Yale researchers are at the forefront of developing new innovative treatment modalities that in 20 years, Dr. Harmanli trusts, "[are] going to fix most these problems."