I'm 43 years old. I work at home as a freelance writer. I have two school-age kids, a husband and a dog. I work out on the treadmill or exercise bike every day and do yoga once a week. I love pizza, the beach and 19th-century novels.
And, oh, yes: I pee my pants nearly every day.
My kids are all too familiar with my last-minute (often past-minute) sprints to the bathroom. They've seen me clutch myself, Michael Jackson style, as I try to staunch the flow. They know well the panicky, wild-eyed grimace that means I'm in urgent need of a potty when there's nary a one nearby.
But until I decided to write this article, they were among the very few who knew my little secret. I've never discussed it with a doctor. Until recently, I'd never even told my husband. The only people I'd talked to about my problem were a few fellow moms, who, in conspiratorial conversations laced with exasperated chuckles, I'd happened to discover were in the same (leaky) boat.
Like the friend who confided that she's never gone a day without wearing a panty-liner since her first baby was born. (That baby's a sophomore in college now.) Or others who report being constantly on guard against sneezing, lifting heavy boxes, even sudden snorts of laughter. And those are the lucky ones: At least they have some clue as to what triggers their trickles. Many women -- including me -- find themselves leaking out of the blue. Yet none of the women I've spoken with has sought medical help.
That, I've learned, is pretty much the norm.
"It's all hush-hush" says William Steers, chairman of urology at the University of Virginia School of Medicine and the National Institutes of Health's clinical trial steering committee on urinary incontinence treatment. "Women have an enormously difficult time mentioning word one about this. For such a common, common problem, it is absolutely silent."
Of course, Steers -- who serves as a consultant to several drug companies including Pfizer and Eli Lilly, both of which have developed incontinence medications -- may have a stake in wanting more public talk about the subject. But so do I.
The silence -- mine and that of the estimated 40 million other women who wet their pants -- is arguably silly. Because, according to experts, most cases of urinary incontinence can be treated -- or even cured -- with medications, behavior modification or surgery. New treatments, including Botox injections and targeted antidepressants, are under study, and more are coming.
To access them, these experts claim, all we need do is get out of the closet and into the doctor's office -- and stop assuming this is a normal part of life.
Paying a Price
Men suffer urinary incontinence, too. But estimates suggest that leaking women outnumber their male counterparts two to one. And while many associate urinary incontinence with aging -- one-third of all Americans over age 60 are affected -- it is not an age-discriminating nuisance, plaguing teens and young moms along with their grannies.
Women tend to keep their incontinence to themselves, says Nicholas Lailas, a urologist with the Reston-based Urology Group. "I think that men are more embarrassed" by incontinence, Lailas says. "But women are such troupers. They just figure 'that's the way it is,' and they accommodate their incontinence."
In fact, says David Thom, associate professor of family and community medicine at the University of California, San Francisco (UCSF), "Several studies have shown that less than a third of women with incontinence seek treatment, and probably less than 10 percent are receiving treatment currently."
Thom's colleague Jeanette Brown, director of the UCSF Women's Continence Center, says that she and Thom "want to make incontinence 'cocktail conversation,' because it is so common, and we know from prior literature if patients discuss their disease with each other, they will seek care."
Inconvenience and embarrassment aside, incontinence poses an enormous -- and "extraordinarily expensive" -- public-health problem, says Steers. Americans spend an estimated $16 billion to $27 billion a year on incontinence-related medical expenses including doctors' visits, absorbent pads, medications and nursing homes. (Incontinence is the number-one reason for nursing home placements, Steers notes.)
Steers adds that urinary incontinence often compels people to stay at home rather than risk being embarrassed by accidents in public. That leads to isolation, he says, which in turn can lead to depression and further physical health problems. "Yeah, it doesn't kill you," he says, "but indirectly it can affect your life expectancy."
But for all that, Steers says, incontinence hasn't received public attention commensurate with its impact.
"There's no bladder sympathy show on TV, no media presentation" of the problem, he says. "Almost every other known disease has a celebrity, but when it comes to incontinence, it's either a cartoon or a taboo . . . Most people don't want to talk about it or think about it," he says. "They're in denial."
A Prod to Action
"Urinary incontinence is not normal," says Lailas. "It's not a normal condition of aging. It's not normal at all."
Steers concurs. "There should almost be a disclaimer on that huge package [of adult diapers] that says, 'Urinary incontinence is not a normal condition. If you're using this product, you really should see a doctor.' "
But don't count on that ever happening. Nor should you expect your primary care physician to ask you whether you're incontinent, Steers says.
So you might have to swallow your pride and raise the subject yourself. But once your problem is out in the open, a urologist, gynecologist, or hybrid specialist known as a urogynecologist will ask questions about your diet, the frequency and other circumstances surrounding your involuntary urination, and your family and personal medical history. You may be asked to keep a "voiding diary" in which you keep track of what you eat and drink and of when you urinate. (Healthy people pee about eight times a day, says Lailas.)
The extent of your bladder capacity and proclivity to leak may be tested in the doctor's office as well. You'll probably need a pelvic exam to rule out other conditions (including urinary tract infections) that can cause frequent voiding.
Type Dictates Treatment
Most women seeking treatment for incontinence benefit from conservative treatments, starting with simple Kegel exercises (contracting, and thus strengthening, the pelvic-floor muscles that support your bladder, uterus and bowels), often in combination with biofeedback, changes in diet, or behavior modification (adopting a strict toileting schedule, for instance). But different forms of incontinence require different approaches.
Stress incontinence is by far the most common type. It's the kind that's triggered by coughing, laughing, snorting, sneezing, heavy lifting and other physical stresses that put pressure on the bladder or cause the urethra (the tube through which urine passes from the bladder out of the body) to drop low. Risk factors include genetics (if your mom and sisters have it, you probably will, too, Steers says), race (Caucasian women are at greater risk for stress incontinence than African-American women), obesity, multiple births (vaginal deliveries) and chronic cough, particularly that associated with smoking. While it's been widely believed that vaginal hysterectomy frequently leads to incontinence, a new study in the July issue of the American Journal of Obstetrics and Gynecology calls that link into question.
Stress incontinence is often treatable with simple measures, like Kegels, with or without biofeedback. But these only work if done regularly, and you won't see results for a month or more. Other treatments include the injection of a bulking agent such as collagen into the lining of the urethra to create temporary resistance against urine flow.
Surgical remedies, generally advised only after other approaches have failed, include insertion of a "sling" or the use of sutures to hold the bladder in place. An artificial urethral sphincter or a stimulus device to promote proper contractions may be implanted. A minimally invasive procedure that uses "tension-free vaginal tape" to support a sagging urethra has a high success rate.
In the U.S. no drug treatments are yet available to treat stress incontinence. In Europe Eli Lilly's drug Yentreve (duloxetine) has recently been approved for that use; it raises levels of the brain chemicals serotonin and norepinephrine, thereby increasing contraction of the urethral sphincter. Lilly is seeking FDA approval to market Yentreve in the U.S. for that purpose. (Lilly already has FDA approval for using the same drug, under the brand name Cymbalta, to treat depression and diabetic neuropathy.)
Urge incontinence is an out-of-the-blue, urgent need to pee that strikes when the bladder contracts even when it's not full. This less prevalent form can be caused by a simple urinary tract infection; it often afflicts women with chronic neurological conditions such as multiple sclerosis (with which I was diagnosed four years ago).
It's also been linked with depression and with menopause, because estrogen depletion thins urethral tissue and also leaves the bladder more susceptible to irritation. African-American women are at greater risk for prolapse of the bladder, a sinking of the bladder into the top of the vagina that's a common cause of urge and stress incontinence.
Urge incontinence is usually treated with medications, either "anticholinergic" drugs, such as the orally administered Ditropan and Detrol, or the Oxytrol transdermal patch, all of which control the bladder's muscle spasms. Antidepressants such as Imipramine alter the way the neurological system interacts with the urination process.
As with stress incontinence, a doctor may recommend Kegels or even an electrical-stimulus implant that stimulates pelvic floor muscle contractions. Injections of Botox, a paralyzing agent, are currently being studied as a means of making the bladder's nerve endings less irritable.
Post-menopausal women may find relief through the use of a vaginal estrogen cream, such as Estrace, or a vaginal ring that releases estrogen. Because estrogen release is localized, says Lailas, neither product poses the general health risks now associated with hormone replacement therapy. Surgery is not usually used.
Mixed incontinence is a double-whammy that affects about a third of all incontinent women, including me. We sometimes pee when we sneeze, sometimes when we're just standing around doing nothing. It's the hardest form to treat, as both the stress and the urge factors have to be addressed, often separately via the means mentioned above.
If, despite all your Kegels and attempts to remove possible irritants from your diet, you find yourself aleak, there's no reason not to consult a doctor. And plenty of reasons to do so.
Lauren Duff, a 54-year-old high school math instructional specialist with Montgomery County Public Schools, says she started experiencing incontinence about three years ago. At the time, she was a classroom teacher, and going for two or three 50-minute classes at a stretch without a bathroom break proved taxing.
Her primary care doctor put her on a medication and left it at that, Duff said. But when things didn't improve, her therapist suggested she see a urogynecologist. An internal exam revealed that Duff had bladder cancer, which was quickly and successfully treated.
Duff's experience was unusual: Inontinence rarely spells cancer. In Duff's case, the two conditions were unrelated and her incontinence was treated through a second medication and weight loss. Still, Duff credits her decision to seek medical attention with the discovery of her cancer. "I think it's kind of cool that my body said, 'Wake up!' " she says.
Her experience also serves as a reminder that, for those with incontinence, time's not on our side. Steers says that among women who end up seeking treatment for incontinence, the average time between onset of symptoms and making that first appointment is eight years.
Eight years of stinky, soiled pants. Eight years of hoping you don't pee on your partner during intimate moments. Eight years of buying pads or stuffing toilet paper in your crotch.
What are we waiting for?
Jennifer Huget, a regular contributor to the Health section, recently wrote about schadenfreude.