Nothing can prepare you for the first time you sneeze or cough and, whoops, there’s a leak that wets your underwear – it’s not meant to happen to you and when it does, it’s mortifying. But it is incredibly common, happening to an estimated 37 per cent of Australian women. And yet, unfortunately, it’s one of the few taboos left in women’s health.
According to the Continence Foundation of Australia, 70 per cent of people never seek advice or treatment, suffering in silence. And up until recently, the advice of many doctors for dealing with incontinence was a vague prescription to do pelvic floor exercises, which just left many women confused and frustrated. Other typical suggestions were even less helpful – wear a pad, don’t drink water before running.
Now, however, a growing number of doctors, continence nurse advisors and physiotherapists are developing more targeted approaches designed to stem leaks once and for all. And they’re sharing a hopeful message (often via podcasts and YouTube): you don’t have to resign yourself to a life of leaks.
“A large majority of women still assume that incontinence is just part of having kids or getting older,” says Amy Stein, a physiotherapist who specialises in the pelvic floor. “But I keep telling them, ‘No, it’s not – you can fix it.’”
Knowledge is power
Putting a stop to those “oops” moments requires understanding what went wrong in the first place, as widespread confusion is often a barrier to effective treatment. Here’s a brief anatomy lesson.
When your system is functioning optimally, the bladder swells as it fills with urine. The urethra, a tube at the bottom of the bladder, serves as the gatekeeper and works with sphincter muscles to hold the urine in place until you’re sitting on a toilet and the brain sends the signal that it’s okay to let go.
The urethra operates with the support of the pelvic floor, a hammock of muscles, tendons, ligaments and nerves that extends from the pubic bone in front to the tailbone in back and outward to the hip joints. But many factors (childbirth, chronic coughing, too much weight, surgeries, and, yes, ageing) can weaken the pelvic floor. When that happens, a sneeze, jump, laugh or other short burst of exertion can put enough pressure on the bladder to momentarily overrun the urethra, resulting in a leak. Picture a teeming herd of cows pressing on a gate just enough to let a few calves loose. In Australia, that condition is called urge incontinence (UI) and the medical diagnosis is overactive bladder.
“There are actually two different types of overactive bladder,” says Elizabeth Kavaler, a urogynaecologists and urological surgeon.
The first, known as ‘overactive bladder dry’, occurs when pelvic-floor muscles are chronically contracted and compress the urethra, giving women a constant urge to urinate even though the bladder isn’t full. And because they can’t relax the muscles fully, they may not empty the bladder fully and may leak or dribble residual urine afterward.
In contrast, ‘overactive bladder wet’ causes frequent urges that lead to accidents.
“When this happens, you can’t make it to the bathroom in time and wind up needing to change your clothes or put on some form of protection,” says Kavaler.
“This is a neuromuscular issue that has to do with the connection between the brain, the spinal cord, and the bladder,” she explains.
Urge incontinence also occurs in women who are older or overweight or have had pelvic surgery. Most women have mixed incontinence, which is a combination of the various types, Kavaler says.
You can stop the drip
All those nuances in the condition mean that treating incontinence properly can be difficult. In the past few years, however, pelvic-floor physiotherapists like Stein, who specialise in continence and the pelvic floor, have started addressing the underlying problems with the pelvic floor in a more substantive way and helping sufferers put an end to leaks, pelvic pain, and the constant urge to go.
When Stein meets with a new patient, she starts by getting a detailed health history, including the woman’s experiences with incontinence. Then, using her hands or biofeedback equipment, she evaluates the strength, endurance, and motor control of the patient’s pelvic-floor muscles to zero in on the problem areas.
Stein looks for any restrictions or shortening of the pelvic-floor muscles, which weakens them. And she assesses whether the pelvic floor and pelvis are properly aligned with the rest of the body and whether a patient’s diaphragm is aligned over her pelvis.
“The diaphragm and the pelvic floor are meant to work almost like a piston,” explains Stein.
Poor posture when sitting or standing can also cause the pelvic floor to malfunction. When patients learn what’s going on anatomically, they often experience a forehead-slapping moment in which they finally grasp the dynamic that’s causing the problem, Stein says.
Take the first step
Pelvic-floor exercises, when done correctly (see the box on the opposite page) are almost always recommended, but that’s not all. Patients dealing with urge incontinence – caused by overactive muscles – may benefit from a type of massage that lengthens the pelvic-floor muscles.
And since pelvic-floor muscles also work in unison with other muscles, a continence physiotherapist will demonstrate how to adjust your alignment so you can strengthen them while getting into your car or doing a yoga pose.
“One of the main goals of such specialised therapy is greater overall awareness of the dynamics at work in that region of the body as it relates to our movements, function and fitness,” says pelvic floor specialist Susie Gronski.
Studies show that women with urge incontinence can experience a 70 per cent reduction in symptoms with pelvic exercises.
Stein says that many patients, especially those with urge incontinence, can see results after six to eight visits without the need for further treatment.
For women who do need a more serious intervention, medication or surgery may be recommended. Women should be referred to urogynaecologists for full assessment if conservative treatment is not successful. A midurethral sling procedure, in which a surgeon implants a narrow strip of synthetic mesh to create a sort of hammock to support the urethra and bladder, can be effective. Patients with more severe urge incontinence may receive treatment involving Botox or other drugs.
With so many treatments now on offer, no one should suffer in silence. Incontinence does not have to be your new normal.
The first step if you would like some help is to talk to your doctor or contact the National Continence Helpline on 1800 330 066. Run by the Continence Foundation of Australia, the helpline is staffed by a team of continence nurse advisors who offer free information, confidential advice and can provide you with a wide range of resources and referrals to your local specialists and services.
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