Last October, I got out of bed to use the bathroom in the middle of the night. Sleepy and seated on the toilet, I was shocked into wakefulness by a loud sound.
The night before, in my latest attempt to manage incontinence, I’d been working out how to use aKegelball, a marble-like vaginal insert that claims to help with pelvic floor strengthening. I’d accidentally fallen asleep with it inside me, and the ball had hit the porcelain bowl.Uh-oh.
I dismounted and stuck my ungloved hand deep into the toilet. Luckily, I was able to retrieve it before it entered the drain pipe, preventing the need for a mortifying 3am call to my super. This was both my first and last time using the Kegel ball.
Eighteen years prior, I had experienced bladder leakage after giving birth, but it resolved within a year. Once perimenopause hit at age 47, however, the condition returned and managing it had become my part-time job.
At the advice of my gynecologist, I’d tried daily self-directed Kegel exercises, tampon-like devices designed to prevent leaks by lifting the urethra and bladder training – or gradually increasing the time between bathroom visits, which I lost interest in pretty quickly. None of these options really worked.
So my bladder kept leaking, usually after laughing, coughing or sneezing. Panty liners were now an essential part of my wardrobe. The worst leaks occurred when I went on a run, and required more substantial protection. I wondered how many other middle-aged women on my Central Park loop had diaper-like devices hidden under their Lululemon leggings.
Probably a lot. More than 60% of US women surveyed from 2015 to 2018reported bladder control challenges. Incontinence often begins after childbirth, due to a combination of estrogen loss and physical trauma, says Dr Meghan Markowski, board certified clinical specialist in women’s health physical therapy at Brigham and Women’s hospital. “Because we have a certain reserve of estrogen, things get better. Then, when we start to lose estrogen in peri- and post-menopause, these symptoms come back with full-fledged vengeance,” she says.
I was an empty nester, recent divorcee and dating again for the first time in decades when incontinence rereared its ugly head. On dates, I’d often scurry away in order to beat the leak. I wondered what these men thought of all those visits to the bathroom – perhaps they suspected I was sneaking drugs or plotting my escape.
Although males are also likely to lose some bladder control with age, middle-aged mendo not experiencethe same surge in incontinence that women do. The men I met were mostly my age and their kids had probably been potty trained a decade ago, or more. Did they really want a partner who was going through the reverse?
If you can’t beat it, talk about it, I decided. And as I started to share, I noticed two things. First, men are usually OK with discussing your vaginal region, no matter the reason. And second, when I revealed my problem to female friends, I learned that I was in good company.
“There’s no reason why this should be taboo,” saidDr Larissa Rodríguez, urologist-in-chief and director of theCenter for Female Pelvic Healthat NewYork-Presbyterian hospital and Weill Cornell Medicine. “For anything that affects women’s quality of life, they should seek care because there are ways to treat it.”
There are two main types of incontinence: stress and urge. Both occur because of a decline in estrogen, which weakens the pelvic floor and thins the lining of the urethra.
Stress incontinence is caused by physical pressure – such as coughing or running – putting stress on the bladder, leading to urine leakage. This is common when the pelvic muscles, which support the urethra, are weak. This is the type I had: unpleasant and inconvenient, but manageable with pads.
Urge incontinence occurs when the bladder contracts more than it should, and can be much harder to live with. “It’s characterized by the sudden compelling desire to pass urine that is either difficult or impossible to defer,” said Markowski. “You could be out shopping, everything’s great, and you go to check out and all of a sudden …Clear the path! I have to get there immediately!”
“For stress incontinence, the gold standard is sling surgery,” said Rodríguez. The sling is “material put under the urethra, like a hammock, so the urethra has something to close against when there’s an increase in abdominal pressure”. Traditionally, mesh is used but it’s also possible for doctors to harvest tissue from the patient, like the lining of the abdomen or the fascia of the thigh muscle.
Alternatively, stress incontinence can be relieved by injecting bulking agents to increase resistance and thickness in the urethral wall. “These are similar to the fillers people use for wrinkles,” said Rodríguez. “They are mostly water-based and close the urethra up a bit.” This is a good option for those who want to avoid surgery. It’s a shorter-term fix, but can last several years.
Urge incontinence can be improved with two types of medication, both of which reduce bladder contractions. The first type, anticholinergics, accomplish this by blocking the chemical messenger acetylcholine, while the second type, beta-3 agonists, relax the bladder’s detrusor muscle, thereby increasing bladder capacity.
If medication fails, Rodríguez said nerve modulation – changing nerve activity via stimulation – is the next step. Inserting a pacemaker near the sacral nerves, which manage the bladder, can result in improved brain-to-bladder communication and control. Acupuncture can stimulate nerves at the ankle, blocking abnormal signals from the bladder and preventing spasms. Another option is injecting botulinum toxin, the same one peopleuse for cosmetic purposes. It relaxes the bladder muscles so you don’t have spasms.
Stress and urge incontinence are both caused by midlife estrogen decline, so ongoing vaginal estrogen supplementation may help, like what’s prescribed for vaginal dryness at menopause, according to Dr Rajita Patil, assistant clinical professor of OB-GYN at UCLA and director of UCLA Health’s comprehensive menopause care program. “It takes a few months to see a difference, and the risks are really low,” said Patil.
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Another highly effective and clinically proven way to prevent and treat incontinence is pelvic physical therapy, which, according to Markowski, is not as simple as doing Kegel exercises. “Without individually assessing someone’s pelvic floor, you have no idea what they’re actually doing. Are the muscles so weak you can’t activate them? Or are they so tense you can’t activate them? The starting function of the pelvic floor muscles will determine the plan of care,” Markowski said. But a training program takes time; Markowski recommends at least three months. If this seems daunting, she suggests at least one pelvic physical therapy session to be properly evaluated and advised.
No matter which treatment you choose, behavior modification is also essential. “Alcohol, caffeine, carbonated beverages and artificial sweeteners irritate the bladder,” said Patil, who also encourages adequate hydration and maintaining a “healthy” body weight. “The more fat there is on the bladder and the urethral sphincter, the greater the pressure exerted on these structures, weakening their ability to maintain closure and increasing the likelihood of urinary leakage.”
Another behavioral strategy is bladder retraining – gradually increasing the time intervals between bathroom visits, improving your ability to hold urine – which my gynecologist had recommended.
A friend mentioned someone who had undergone a sling surgery, which I’d never heard of. It seemed like a great option, and I could hardly contain my excitement. A week after turning 50, I made an appointment with a urogynecologist.
“I’m tired of peeing in my pants,” were my exact words. “Please fix me.”
A bladder test determined that I had stress incontinence. I scheduled the surgery, an outpatient procedure covered by insurance. Recovery was virtually painless; I didn’t even take any Tylenol. I stayed home for a few days, and was told not to exercise or “stick anything in the vagina” for four weeks. The hardest part was not being able to work out, but the anticipation of pad-less runs made it worth the wait.
Now, two months post-surgery, my runs are pee-free. Last week, I visited my surgeon to reperform the bladder test. She made my bladder uncomfortably full via a catheter, then asked me to make a small cough. Then a medium cough. Then a loud one. My underpants remained as dry as a bone.
According to my surgeon, I should be “fixed” for at least the next 10 years. And physical therapy, though not mandatory, could make the results last longer.
Still, there is no such thing as a perfect solution, and treatments may work best when combined with others. Markowski, who’s dedicated over 20 years to helping patients non-surgically, acknowledges that physical therapy might not be enough to resolve symptoms in all cases: “We always want to start with the most conservative measures and up the ante as time goes on, with meds or surgery. But surgery doesn’t change the muscle function, so in many cases, even the surgeon will want their patient to undergo physical therapy.”
Rodríguez, a surgeon, concurs: “I am a strong believer in physical therapy, and pilates is also quite good in getting people to engage the pelvic floor.”
The best thing I ever did about my incontinence was start talking about it. Chances are, if you share, you’ll learn that you’re not alone. If you’re really lucky, you’ll even find someone to laugh with you about it. And if you pee a little when you do, you won’t be the only one.
Amanda Klarsfeld is a freelance writer in New York City.