Category: Urinary Incontinence

by Marcelle Pick, OB/GYN NP

Getting your bladder back on track — living with Interstitial Cystitis

• What is interstitial cystitis and why haven’t I heard of it?
• The possible causes of IC
• IC, estrogen, and menopause
• Discovering your trigger foods
• The Women to Women approach to treating IC

Frequently, I am asked a myriad of questions from women who are suffering with intense pelvic discomfort as well as women who have the urge to urinate frequently. For a number of women, constant trips to the bathroom control their lives. Some of these women go to the bathroom as often as 60 times a day and 10 times during the night! Numerous women are desperate to minimize an extremely painful, stabbing pain in their pelvis. The good news is that today, women have a variety of avenues they can explore when it comes to these symptoms, a common one; however, often misdiagnosed – a bladder condition called interstitial cystitis (IC), or painful bladder syndrome (PBS) is something I want to talk about.

Interstitial cystitis affects more than 1.2 million people in the United States, 90% of whom are women. Interstitial cystitis can affect women at all stages of life, from puberty to menopause, all of which have unique challenges with this condition. The condition is extremely uncomfortable and leads many women to search for answers. It is important to understand that our hormones, particularly estrogen, play a large role in managing (or even preventing) the inflammation that relates to IC. Even though the symptoms can feel similar to a urinary tract infection (UTI), nobody has been able to identify an infectious agent to date: consequently the condition won’t show up on regular urine cultures for bacteria and other pathogens. Unfortunately, taking antibiotics won’t help either. Nor will drinking more cranberry juice — natural UTI treatments can in fact make IC symptoms worse.

Interstitial cystitis can be downright unbearable for some women, preventing them from going to school, work, or participating in any of their normal day-to-day activities, not to mention making their sex lives very painful. Too often women just “live with it” for years before looking for help. Or a woman could see up to five different practitioners over the course of many years before being accurately diagnosed with Interstitial cystitis! I would like to talk a little bit more about this remarkable condition as well as look at what you can do to protect your bladder — as well as your sanity and over all lifestyle. Many different techniques have been tried but none have a huge success rate to date.

What is Interstitial Cystitis, and why haven’t I heard of it?

The symptoms of IC are easily confused with a wide range of other problems, from bladder infections (UTI’s) and urge incontinence to bladder cancer, endometriosis, STD’s, and kidney stones. These disorders have different root causes and need different types of treatments. A lot of women with IC see their healthcare practitioners thinking they have a UTI and are told their urine is “clean” —that means on culture that no abnormalities were seen in the urine when it was evaluated in the lab. If there is no detected “problem,” it frequently means that there simply is no easy solution for women.

There now exists diagnostic criteria for IC established by the National Institutes of Health Let’s look at what they are:

• Bladder and low pelvic pain
• Urinary urgency and frequency
• Small bladder
• Evaluation for Hunner’s ulcers (only affects about 10% of all cases)

Interstitial cystitis is most often recognized as a chronic neuroinflammatory disorder affecting the bladder — a complex interrelationship between bladder nerves, the immune system, and the urinary tract. Untreated, IC can lead to scarring or stiffening of the bladder walls as well as an inability to hold much fluid in your bladder. Glomerulations, which are identified as hemorrhages in the mucosal lining of the bladder, and can also develop star-shaped sores called Hunner’s ulcers, this is seldom seen in clinical practice.

As more medical professionals learn to identify the IC conditions, they are better able to help women manage as well as overcome this disorder. The Interstitial Cystitis Association and the Interstitial Cystitis Network are wonderful organizations that are promoting more awareness of the varied causes and symptoms so more women can get relief.

Possible causes of interstitial cystitis

We are still learning about IC, and to date there is no known cause that has been identified. There are probably many “insults” to the bladder that could lead to interstitial cystitis. What is clearly understood though is that inflammation is at play, with immune dysfunction, specifically allergies and sensitivities, having a central role. Here are a few possibilities. There does seem to be some ties with autoimmune disorders as well.

Chemicals in urine: Urine itself can be an irritant in the urinary tract, mainly if tissues were previously damaged from other primary causes. Urine will change as the diet changes. Studies show that patients with IC have a molecule in their urine called antiproliferative factor (APF). APF inhibits the normal growth of bladder wall cells, making it problematic for your bladder to repair itself if scarred.

Mast cell activation. Studies have shown that some of the contents found typically in our urine (like potassium, for example) can infiltrate the bladder lining in IC patients, leading to mast cell activation and the release of histamine — which can then result in further damage to the bladder lining and amplified inflammation. More than 70% of women with IC have highly activated mast cells. Again this is an example of the inflammatory system being on high alert.

Previous bladder damage: A number of factors can damage the bladder, making it more susceptible to the interstitial cystitis. Some of which include:

• A history of bladder trauma, especially including pelvic surgery
• Spinal cord trauma
• Pelvic floor muscle dysfunction
• Bladder over distention
• Inflammation of pelvic nerves
• Autoimmune disorders
• History of frequent bladder infections
• Chronically Low estrogen

Interstitial cystitis, estrogen, and menopause

So many women remark that symptoms of IC ebb and flow with the natural hormonal shifting that occurs in our bodies monthly. Furthermore, some notice their first symptoms throughout the perimenopausal time frame. Why, you might ask? Well, it most likely has something to do with estrogen levels. A reduction in estrogen levels can activate our mast cells. Estrogen is an anti-inflammatory agent.

When evaluating bladder mast cells researchers at Tufts who examined the mast cells under an electron microscope also noticed a large number of estrogen receptors in cells from women with IC. The net result in these women is similar to hormones that are imbalanced. They described this as similar to a progesterone deficient state which lead to increased mast cell secretion of histamine. This is the body’s immune response to an offender.

In looking at the bladder’s anatomy, the bladder lining and the muscle that essentially governs urination, the detrusor, are greatly affected by inflammation, mast cell activity, and estrogen. If we have ongoing low-grade inflammation over the course of multiple years, particularly when coupled with significant hormonal fluctuations during perimenopause and menopause, the tissues and muscle can become thinner and drier — and even more susceptible to inflammatory changes. As a result without restoring our hormonal balance, there is a greater chance that we can become more susceptible to IC.

However, women have options when it comes to treating and managing interstitial cystitis. A good place for women to start is by looking at their diet and lifestyle.

Discovering your triggers — an IC elimination diet

Subsequently a lot of women say that their symptoms decrease when they follow an alkalizing, anti-inflammatory diet by avoiding certain trigger foods, and by eliminating caffeine, alcohol and smoking. Tobacco is a particularly common trigger because it constricts the bladder’s blood vessels, making it harder for our bodies to naturally cleanse inflammatory substances from the bladder tissues.

Here are the some of the foods that the Interstitial Cystitis Network calls “the most problematic” because they trigger the most symptoms in the most people. These top offenders are an excellent place to start:

• Coffee. The acid and caffeine in coffee can cause intense irritation and discomfort. Additionally, caffeine acts as a diuretic. Therefore lowering your coffee consumption to 12 oz. or perhaps much less per day is really a wise decision – in fact, a lot of women with IC really need to completely eliminate coffee to feel significantly greater pain relief. Tea. Black teas and even decaffeinated teas can spark inflammation in your bladder. Everyone is different so just trying this for a few days may bring great relief. Green teas and some herbal teas also have a tendency to have a certain level of acidity. Nearly all women are (quite understandably) unwilling to give up their delicious hot drinks, but you can try some other options such as hot water with grated ginger and honey or mint teas containing only peppermint or spearmint leaves.

• Cranberry and other acidic fruit juices. Cranberry juice is actually frequently recommended for the treatment of urinary tract infections, but an IC bladder is extremely irritated from the level of acidity in cranberry juice. So if juice is a must for you, try less acid varieties like pear, apple, and blueberry. Pear juices and pear sweeteners are really considered your safest bet.

• Diet soda. Your average diet soda contains four major bladder irritants in one shiny can: acidic carbonation, citric and phosphoric acids, caffeine, and artificial sweeteners. In case you absolutely need to have a soda pop, we recommend a non-diet, non-caffeinated root beer, and diluting it with ice cubes or water is certainly a lot better.

• Tomatoes. Though they’re full of so many good things, tomatoes are also high in potassium, and are highly acidic, too. For tomato-lovers, low-acid varieties might be substituted as an occasional treat.

At Women to Women, we would add a few additional items to this list of top offenders.

In our experience, the following substances also have the potential to trigger symptoms:

• Artificial food colorings (dyes) and flavorings. Food colorings happen to be incredibly common in food (even several health foods) in addition to the majority of over-the-counter multivitamins and prescription medications.

• Foods that promote yeast. Sugar, vinegar, yeast, malt and other foods can cause yeast overgrowth. You may want to follow a yeast-free, sugar-free diet — many of the women we see with IC symptoms are found to have systemic yeast, but once the yeast overgrowth is resolved, the IC symptoms abate. This is almost always an issue when we do the workup for IC.

• Gluten. This problematic, inflammatory protein is found naturally in grains and also in several other foods through additives and contamination. Read our article on gluten sensitivity for more on the effects of gluten and how to address them with a gluten-free diet.

• Certain nutrients. A number of women truly have allergies or severe sensitivities to certain nutrients — which is why you may read advice recommending that women with IC discontinue multivitamins. If you cannot find other causes for your allergic reaction to foods, consider NAET — an allergy elimination technique that has helped countless people overcome problematic allergies and sensitivities.

Once you learn just what foods set you off, you can begin to create a list of your trigger foods. Once you feel a lot better – which frequently will happen in just a week or two – experiment with just how much of each and every food your body definitely will process comfortably. Take heart: even the strictest IC diet doesn’t have to last forever. (The initial dietary changes are about calming down the bladder). But changing to a more alkalizing diet has tremendous overall health benefits for your body, and I know plenty of women with IC who are able to enjoy all of the above foods in smaller amounts!

The Women to Women approach — options for treating Interstitial Cystitis

Presently, there is not a cure for interstitial cystitis; however there are effective treatment options that do exist. Because our bladders can have trouble repairing themselves when we have IC, it is important that women speak with their healthcare practitioner as well as their urologist about the best IC treatment for them.

Here are some options:

• Keep a bladder diary. If you are suffering from very painful bladder, or even more frequency than normal, always keep a personal bladder diary. For 24 hours (or more), jot down what you eat and drink (and smoke), how often you experience the urge to urinate, the level of your pain intensity, and how relieved your bladder feels after urination. You are then able to take your bladder diary with you any time you visit your healthcare practitioner to assist in figuring out patterns and whether or not you could have IC or not. This is one of the only ways for you to see the associations that may not have been seen otherwise.

• Understand your triggers. See the section above on common interstitial cystitis triggers and learn what you can modify in your diet to lessen your symptoms. Everyone is different and has different triggers.

• Follow an IC/alkaline diet. Actively managing the acid–alkaline balance in your body can help all urinary disorders, and lessen your discomfort. It has also helped women cut down on the foods that cause other inflammatory issues in their bodies To start, there are amazing cookbooks that can get you started with some excellent recipes. One excellent resource is A Taste of the Good Life: A Cookbook for an Interstitial Cystitis Diet.

• Balance your hormones. Estrogen plays a significant role in inflammation, and during times of great hormonal imbalances your body could be more susceptible to inflammation that can lead to interstitial cystitis. Consider a natural approach to hormonal balance in your system, such as a soy supplement. Many women also think about more potent natural hormone therapies when needed. In my practice this is almost always something I will start with.

• Investigate anti-inflammatory supplements. For numerous women, calcium citrate can promote a more alkaline system and reduce the inflammation that contributes to issues like IC and vulvadynia/vestibulitis. Also turmeric is a fabulous anti-inflammatory agent along with boswellia. In addition, omega-3s have long been known for their ability to decrease systemic inflammation in the tissue and membranes.

• Probiotics also help restore normal flora and lessen inflammation, plus help to combat systemic yeast triggers. Also, Quercetin, is an antioxidant in the flavonol group with marked anti-inflammatory actions. It is also very effective to decrease systemic allergic responses. Quercetin-containing supplements are exceptionally well tolerated and are reported to provide considerable symptomatic improvement in patients with IC.

• Try physical therapy. Most people with IC also have severe pelvic floor dysfunction, a condition in which the muscles of the pelvic floor do not relax enough to allow easy urination. They also may have alignment issues as well. Physical therapy to rehabilitate the pelvic floor is very helpful in easing the pain of IC, as is bladder “retraining” to gradually expand the time between trips to the bathroom. And a technique called myofascial tissue manipulation and polarity therapy shows promise for reducing IC symptoms.

• Address body and mind. Various women have regular acupuncture treatments or biofeedback to relax the bladder and detrusor muscles. At Women to Women, we have referred patients for education in the Feldenkrais method, and integrative manipulative therapy with great success Guided imagery is also a readily available interventive step with no harmful side effects — in a study on guided imagery published in 2008, IC patients reported significant improvement in pain and IC symptom management.

• Investigate conventional approaches. Based on the seriousness of your symptoms, you could possibly first try less invasive therapies, but if you do not experience improvement, don’t give up hope – nothing is going to help every woman the same exact way. You can always talk to your practitioner about more conventional treatments, and seeing a urologist or uro-gyn specialist who is familiar with cutting edge IC treatments available, such as:

• Oral medications. Antidepressants can block pain for a number of women. These medications seem to work by interfering with nerve activity, and their effect may also prevent psychological stress, which can activate mast cells. Stress can be a significant aggravator. A number of researchers are developing treatments based on AFP, such as the prescription medication Elmiron, which “coats” the bladder wall to protect it, thereby reducing irritation and inflammation. Numerous experts now believe you can just start a trial of this medication based on symptoms, without need for painful cystoscopy testing.

• Bladder treatments. A number of women with especially severe cases of IC have treatments that include bladder distensions (stretching the bladder during a cystoscopy), or by inserting drugs that inhibit inflammation and pain into the bladder through a catheter. Heparin and even Elmiron can be used in this manner.

• Surgery. For women who cannot get pain relief elsewhere, surgery to expand the bladder remains a last resort — but since so many women find success treating their IC in other ways, surgery is fortunately uncommon.

Get out of the bathroom and back to your life!

There are certainly choices for you when you have interstitial cystitis. The first thing I recommend that you do is to talk to your healthcare practitioner about a combination of natural approaches that would work best for you, along with the IC diet in order to seek relief. Because with the right treatments, whether naturally and holistically, or through conventional medicine, the majority of us can learn how to manage our IC symptoms well enough to get out of the restroom, and back to our lives!

IC is often misdiagnosed as…

• Urinary tract infection
• Vaginitis
• Urge incontinence
• Chlamydia, herpes, and other STD’s
• Kidney stones
• Endometriosis
• Bladder cancer

by Marcelle Pick, OB/GYN NP

The hourglass shape of a woman’s body allows the pelvis to provide primary support for everything above it. The pelvis is the foundation upon which much of the body’s structure rests, and just as with any other kind of structure, it’s important that this foundation be solid — after all, the rest of the body depends on it.

One critical area of the pelvic “foundation” in women is a set of interwoven muscles called the pelvic floor. These muscles cradle our lower internal organs, much like a hammock holds a person, while encompassing three important passageways: the urethra, vagina, and rectum. When the floor of the female pelvis is compromised, it’s easy to see how many things can go wrong — from painful intercourse to incontinence and urinary tract infections. I know it’s easy to take our pelvic and urinary health for granted, but when pelvic health becomes an issue, it can have a tremendous impact on our lives and our overall health.

I’ve seen so many women at the clinic — young and old, with children and without — devastated and embarrassed about urinary incontinence. It affects more women than you may realize. Chronic infections, surgery, childbirth, accidents and many other things can cause changes in the urethra and the bladder that result in urinary and even bowel incontinence. But rest assured, there are solutions. Pelvic floor exercises, pelvic physical therapy (PPT), acupuncture, and good nutrition are just some options we’ve found helpful for bladder and bowel control in women.

Another major area of concern for our patients is urinary tract infections. Whether you can’t seem to get rid of them or you want to focus on preventing UTI’s, we’ve had years of experience. And the answer does not always include antibiotics. There are so many ways to boost your immune system and prevent recurrent infections from both yeast and bacteria without resorting to prescription medication. You may be wondering, is cranberry really the answer? What about vitamin C? Find the answers you’re looking for. And take good care of your foundation!

 

by Marcelle Pick, OB/GYN NP

Don’t just live with urinary incontinence — learn about the causes of incontinence so you can move forward

The other night I was at a charity event and a friend introduced me to a group of eight women whose ages ranged from 35 to 50. One of them asked me what I was working on and I decided to be frank and say I was putting the finishing touches on an article about urinary incontinence in women.

You should have heard the outcry! Each woman had a different story to tell. One had to leave her aerobics class after her shorts got soaked. Another abandoned a grocery cart full of food in the check-out line to sprint for the public bathroom. Another organized her day around easy access to the toilet.

Every woman in that group (some were mothers, others were not) had some experience of losing bladder control. Most seemed to think it was an inevitable part of aging — complete with the requisite adult diapers or incontinence surgery.

Stress incontinence and overactive bladder (OAB), or a mixture of both, are extraordinarily common — but nobody wants to talk about them. In the past, traditional medicine viewed incontinence as primarily a men’s issue. But in my experience almost all women will suffer at some point in their lives from some form of urinary incontinence. What’s more, our bladder control issues can leap from moderate (or non-existent) to severe with the onset of menopause, especially for women who never experienced childbirth.

It’s high time we bring urinary incontinence out into the light and talk about it. Women are so conditioned to suffer in silence, but it’s not good for our health. In fact, women rarely mention urinary incontinence in their annual visits with me. So I ask. Incontinence may not be entirely avoidable as we get older, but it is certainly treatable, and there are very effective alternative methods.

What is female urinary incontinence?

A sudden urge to go, leaking urine and frequent urination are all forms of urinary incontinence, which is generally defined as a lack of bladder control. While there are many causes, the most basic is a gradual weakening of the pelvic nerves, organs and smooth muscles that are meant to work together to control urination.

The bladder itself is a sac that stores urine from your kidneys. When it’s full, pelvic nerves send a signal to the brain that you have “to go”. Your pelvic muscles, especially the sphincter of the urethra, clench and “hold it” until you get to the bathroom. Once you’re there and safe, your brain tells the sphincter muscles to relax and your bladder empties.

Believe it or not, the muscle anatomy “down there” is still not completely understood by modern medicine. We do know it’s an intricate and amazing arrangement of dozens of muscles which keeps things in and lets them out as necessary. Of course the female pelvic floor is much more complex because women have babies.

But a lot can change in the course of a lifetime. Inner pelvic muscles stretch and atrophy with age, pregnancy, gravity and trauma. Muscles lose their elasticity from lack of use and loss of estrogen. Organs actually move around, often pressing on the bladder itself. In some cases the bladder or urethra become damaged or chronically inflamed and malfunction. Scarring from surgery, injury or infection may disrupt the natural alignment of the organs inside the pelvic area.

And when you think about it, which of us doesn’t experience several of those factors over time?

by Marcelle Pick, OB/GYN NP

As if the hot flashes and mood swings weren’t enough, many of us going through menopause start to experience more episodes of urinary incontinence. A decrease in estrogen initiates a thinning and weakening of the pelvic muscles and connective tissue — our house just starts to sag a little.

The relationship between bladder control and hormonal balance becomes increasingly important as we get older and transition through menopause. Some of us have been keeping an eye on the bathroom all along the way, but what about those women who never had an awkward leaky moment until their 40’s or 50’s?

We’re now seeing more ads for pharmaceuticals directed at female incontinence (somebody finally noticed!) but as usual, they only address the most obvious symptoms and do nothing to treat the underlying loss of muscle tone. Most of the drugs available act on the muscle spasms related to overactive bladder but do nothing for stress incontinence and can cause other bothersome side effects.

As with any drug or synthetic hormone, you need to weigh the long-term risks against the potential benefits before taking a pill that could do serious long-term damage to your health. Of course, we recommend you try the most natural steps first, and resort to drugs only if necessary to get symptom relief.

After menopause, women are more prone to bladder infection, chronic urinary tract infection (UTI) or cystitis. As the urethral muscle loses strength and elasticity due to loss of estrogen, pockets of bacteria can flourish. Taking an antibiotic — nowadays there’s a one-day massive dose — is usually adequate, but in some cases inflammation takes hold and damages the lining of the bladder.

This condition, called interstitial cystitis (IC), is a growing concern in women’s health that warrants an entire article of its own. It’s an inflammatory condition that manifests with all the symptoms of a urinary tract infection even when no bacteria are present. It would not surprise me to find in the future that estrogen imbalance is somehow implicated in the escalating rates of interstitial cystitis that I’m seeing.

The emotional connection to the bladder

In Chinese medicine, the bladder is related to issues of anger and control — there’s ancient wisdom at work when we say we’re “pissed off”.

In yoga, the root lock — or mula bunda in Sanskrit — is located at the base of the perineum. It is one of the three major body locks that control our inner life force, or kundalini. (Note that this inner life force is considered to be female!). It is closely related to the earth and the force that connects all living things. Lifting the mula bunda creates stability and energy within the body (as you do with a Kegel exercise — discussed below), channels our life force up through the chakras and imbues our bodies with a sense of weightlessness.

Incontinence can sometimes be a physical manifestation of some deep-seated fear or worry that weighs us down. It’s often related to anxiety or anger about losing control. Occasionally, sporadic episodes of incontinence will occur during a particularly stressful — or “out-of-control” — phase of your life. Pay attention to your feelings and see if you notice any patterns.

by Marcelle Pick, OB/GYN NP

Don’t just live with urinary incontinence — learn about the causes of incontinence and what you can do about it! Here are the topics discussed in this article:

• What is female urinary incontinence?
• The anatomy of the pelvis
• What type of bladder problem is it?
• What causes incontinence in women?
• Urinary incontinence after hysterectomy
• Bladder problems after menopause
• The emotional connection
• Urinary incontinence treatment — what you can do

The other night I was at a charity event and a friend introduced me to a group of eight women whose ages ranged from 35 to 50. One of them asked me what I was working on and I decided to be frank and say I was putting the finishing touches on an article about urinary incontinence in women.

You should have heard the outcry! Each woman had a different story to tell. One had to leave her aerobics class after her shorts got soaked. Another abandoned a grocery cart full of food in the check-out line to sprint for the public bathroom. Another organized her day around easy access to the toilet.

Every woman in that group (some were mothers, others were not) had some experience of losing bladder control. Most seemed to think it was an inevitable part of aging — complete with the requisite adult diapers or incontinence surgery.

Stress incontinence and overactive bladder (OAB, also known as urge incontinence), or a mixture of both, are extraordinarily common — but nobody wants to talk about them. In the past, traditional medicine viewed incontinence as primarily a men’s issue. But in my experience nearly all women suffer at some point in their lives from some form of urinary incontinence. What’s more, our bladder control issues can suddenly leap from moderate (or nonexistent) to severe with the onset of menopause, and especially take women who have never experienced childbirth by surprise.

It’s high time we bring urinary incontinence out into the light and talk about it. Women are so conditioned to suffer in silence, but stoicism that leads us to keep our health concerns quiet is not good for our health. In fact, women rarely mention urinary incontinence in their annual visits with me. So I ask! Incontinence may not be entirely avoidable as we get older, but it is certainly treatable, and there are very effective alternative methods. Let’s discuss what can be done both to prevent and to find relief from female bladder problems.

What is female urinary incontinence?

A sudden urge to go, leaking urine, and frequent urination are all forms of urinary incontinence, which is generally defined as a lack of bladder control. While there are many causes, the most basic is a gradual weakening of the pelvic nerves, organs and smooth muscles that are meant to work together to control urination.

The bladder itself is a sac that stores urine from your kidneys. When it’s full, pelvic nerves send a signal to the brain that you have to “go.” Your pelvic muscles, especially the sphincter of the urethra, clench, and “hold it” until you get to the bathroom. Once you’re there and safe, your brain tells the sphincter muscles to relax and your bladder empties.

Believe it or not, the muscle anatomy “down there” is still not completely understood by modern medicine. We do know it’s an intricate and amazing arrangement of dozens of muscles which keeps things in and lets them out as necessary. Naturally, the female pelvic floor is much more complex than the male pelvic floor because women have babies.

But a lot can change in the course of a lifetime. Inner pelvic muscles stretch and atrophy with age, pregnancy, gravity and trauma. Muscles can lose their elasticity with lack of use and loss of estrogen. Organs actually move around, often pressing on the bladder itself. In some cases the bladder or urethra may become damaged or chronically inflamed and malfunction. Scarring from surgery, injury or infection may disrupt the natural alignment of the organs inside the pelvic area.

And when you think about it, which of us doesn’t experience several of these factors over time?

House beautiful: the anatomy of the pelvis

You may have noticed the anatomical chart in your healthcare provider’s office of a woman’s internal organs. In that image, all of our parts are stacked neatly and well-supported within cushioning bands of smooth muscle. The vagina and the uterus nestle snugly between the urethra and bladder in front and the rectum and colon just behind.

There are several important ideas I want you to grasp from this picture to help you understand the help we have to offer for urinary incontinence:

• This elegant anatomy relies on the strength and tone of our pelvic muscles and ligaments, particularly the pelvic floor and perineum, to keep everything in its proper place.
• There is a lot of complexity in a small area — where our urinary tract, our reproductive tract, and our intestinal tract all converge. Changes in one of these systems can and do affect another.
• The bladder — and all the pelvic tissues and organs — are exposed to so many adverse developments in this picture, from posture to digestive problems, and some number of those adverse developments are inevitable as we get older.

Types of bladder problems

Before we talk about how to relieve incontinence (sorry for the pun, but we have to keep our sense of humor!), let’s explore the different types of incontinence that women experience.

Stress urinary incontinence (SUI), also called light bladder leakage (LBL), is related to the weakening of the pelvic floor resulting in pressure (or stress) on an otherwise fully functioning bladder. One minute you’re laughing, sneezing or coughing, the next moment your underwear is wet. I know very few women who have not experienced some degree of stress incontinence at some point or another. Exercise (particularly jumping), orgasm, and even hearing running water can trigger it — often with greater regularity after menopause. It’s true that pregnancy and childbirth and pregnancy are frequently to blame for stress incontinence, but we also see a lot of women with stress incontinence at our practice who have never borne children.

Urge incontinence (UI) or overactive bladder (OAB) is a sudden, uncontrollable need to go, even if you just went ten minutes ago. It’s a result of uncontrolled contractions of the bladder muscle (called the detrusor) caused by a disruption in communication between the bladder and the brain. This happens due to inflammation of the bladder lining, infection, injury, natural atrophy that comes with age, or other reasons. Waking up once to several times at night to pee, called nocturia, is a common OAB complaint, as is accidental wetting due to an unstoppable urge to void. Sometimes overactive bladder is the result of overflow incontinence (see below).

Prescription medications for urge incontinence can either relax the detrusor muscle (e.g., Sanctura) or block the nerve impulses that prompt the bladder to contract (e.g., Detrol), which can be helpful for OAB, but they do not relieve symptoms of stress incontinence. They can also cause many side effects, including dry mouth, constipation, headache, blurred vision and dizziness, to name a few.

Many of our patients come to our medical clinic with a combination of both stress and urge incontinence, which is classified as mixed incontinence.

Overflow incontinence occurs when you can’t evacuate all the urine in your bladder because muscle tone is weak or you have a blockage. Symptoms of overflow incontinence include dribbling, urgency, hesitancy, straining, a weak urine stream or low urine production even though your bladder feels full. It’s more common in men, but overflow incontinence occurs in a significant number of women as well.

Once you and your healthcare provider have a better idea of what type of urinary incontinence you’re experiencing, you will have a better chance at getting to the root causes and deciding on the best form of treatment.

What causes incontinence in women?

Sometimes the smooth muscle of the vaginal wall or the perineum overstretches and herniates, allowing the bladder or urethra to balloon through the weakened muscle. This herniation creates a pocket in the vagina known as a cystocele or urethrocele, which makes it difficult to fully empty the bladder or stretches the opening of the urethra, causing stress incontinence. You can usually feel a cystocele or urethrocele as a smallish, smooth bulge in the anterior (front) or side wall of your vagina. Overstraining, childbirth, and injury are the most common causes of cystoceles and urethroceles prior to menopause. After menopause, the natural thinning of the muscles is the more common culprit.

Chronic infection, surgery, medications (including synthetic HRT), radiation, adhesions, and disease are other factors that affect bladder function and the architecture of the muscles and nerves in the pelvis — and they can all contribute to issues with incontinence.

You are more likely to develop urinary incontinence if you have had significant trauma to the pelvis, spine or bladder, surgery, a disability or impaired mobility (which can make it hard to get to the bathroom). We often see a connection between incontinence and a car accident that occurred years beforehand, especially when those accidents were followed by a change in posture or chronic pain. Stroke, Alzheimer’s, multiple sclerosis (MS), and other central nervous system conditions are also associated with urinary incontinence. Some medications can also cause a loss of bladder control.

Systemic yeast, local yeast infections, and food allergies also play a role in bladder infections and interstitial cystitis. And, as in all inflammatory conditions, our emotions play a role in fueling the fire. For more on this, see our articles on inflammation. Smoking, obesity, and chronic constipation (with straining) are additional proven risk factors for developing incontinence over time.

Now let’s spend a moment on the link between hysterectomy and urinary incontinence.

Urinary incontinence after hysterectomy

Hysterectomy increases the odds of incontinence for two main reasons: the design and support of the pelvis is permanently changed, and women often lose the muscle-toning effects of their natural sex hormones post hysterectomy, even if their ovaries have not been removed.

A radical hysterectomy can cause extensive scarring that disrupts your inner musculature and nerves. If at all possible, we recommend having the least invasive hysterectomy available and keeping the ovaries intact. Many surgeons are now capable of performing a laparoscopic hysterectomy, which involves far less damage, or a modified procedure to ablate the uterine lining or embolize the arteries to the uterus without hysterectomy.

Keeping your ovaries is important when it comes to incontinence because of the beneficial effects of estrogen on the muscles of the bladder, bladder lining, and urethra, and on the connective tissues within the pelvis. Even so, in over half the cases, women who keep their ovaries still suffer some loss of ovarian function after hysterectomy, with negative effects on their hormonal balance. For more information, see our article on hysterectomy and hormones.

Studies also show that synthetic hormone replacement therapy increases a woman’s risk for stress incontinence, and we don’t recommend synthetic HRT in any form but prefer to administer bioidentical hormones transdermally or via lozenges. Topical bioidentical estrogen clearly helps promote a natural elasticity and suppleness in the pelvic floor. We’ve seen patients with UI respond extremely well to bioidentical estrogen cream applied directly to the vaginal wall and particularly the area near the urethra.

Bladder problems after menopause

As if the hot flashes and mood swings weren’t enough, many of us going through menopause start experiencing more episodes of urinary incontinence. A decrease in estrogen initiates a thinning and weakening of the pelvic muscles and connective tissue — our house just starts to sag a little.

The relationship between bladder control and hormonal balance becomes increasingly important as we get older and transition through menopause. Some of us have been keeping an eye on the bathroom all along the way, but what about those women who never had an awkward leaky moment until their 40’s or 50’s?

We’re now seeing more ads for pharmaceuticals directed at female incontinence (somebody finally noticed!). But, as usual, they only address the most obvious symptoms and do nothing to treat the underlying loss of muscle tone. Most of the drugs available act on the muscle spasms related to overactive bladder, but do not treat stress incontinence. What’s more, they can cause other bothersome side effects.

As with any drug or hormone, you need to weigh the long-term risks against the potential benefits before taking a pill that could do serious long-term damage to your health. Of course, we recommend you try the most natural steps first, and resort to drugs only if necessary to get symptom relief.

After menopause, women are more prone to bladder infection, chronic urinary tract infection (UTI) or cystitis. As the urethral muscle loses strength and elasticity due to loss of estrogen, pockets of bacteria can flourish. Taking an antibiotic — nowadays there’s a one-day massive dose — is usually adequate, but in some cases inflammation takes hold and damages the lining of the bladder.

This condition, called interstitial cystitis (IC), is a growing concern in women’s health that warrants an entire article of its own. It’s an inflammatory condition that manifests with all the symptoms of a urinary tract infection even when no bacteria are present. It would not surprise me to find in the future that estrogen imbalance is somehow implicated in the escalating rates of interstitial cystitis that I’m seeing.

The emotional connection to the bladder

In Chinese medicine, the bladder is related to issues of anger and control — there’s ancient wisdom at work when we say we’re “pissed off.”

In yoga, the root lock — or mula bunda in Sanskrit — is located at the base of the perineum. It is one of the three major body locks that control our inner life force, or kundalini. (Note that this inner life force is considered to be female!) It is closely related to the earth and the force that connects all living things. Lifting the mula bunda creates stability and energy within the body, channels our life force up through the chakras, and imbues our bodies with a sense of weightlessness. You can access this life force with kundalini yoga postures and Kegel exercises, as discussed below.

Incontinence can sometimes be a physical manifestation of some deep-seated fear or worry that weighs us down. It’s often related to anxiety or anger about losing control. Occasionally, sporadic episodes of incontinence will occur during a particularly stressful — or “out-of-control” — phase of your life. Pay attention to your feelings and see if you notice any patterns.

Urinary incontinence treatment — what you can do right now

Bladder issues are like so many health-related concerns — the sooner you attend to them the easier they are to treat. So here’s what you can do:

See your healthcare provider. If you are noticing any urine leakage or an increased frequency of urination, the first step is to get checked out by your healthcare practitioner. Depending upon the situation, you may find it useful to consult further with a gynecologist, urogynecologist, or urologist.

When we see women for bladder problems, we first try to figure out what kind of urinary incontinence they are dealing with. Most often this is some form of mixed incontinence that can be treated through alternative therapies.

Pelvic floor exercises. In cultures where women squat to do their work, there is a much lower incidence of incontinence. Most women don’t do much in the way of that kind of labor anymore — but we’ve got Kegel exercises! Incontinence can often be arrested or reversed with Kegel exercises alone. Named after an American ob/gyn, these simple exercises are really an adaptation of the “root lock” of kundalini yoga without the trappings. You can do them anywhere, anytime — and you should.

To do a Kegel, imagine that you are trying to stop yourself from urinating. Practice both short and long Kegels. You can even do an anticipatory Kegel before you sneeze or cough and prevent leakage! For more information on Kegel exercises for urinary incontinence, visit the University of Iowa Hospital and Clinics’ website.

A wonderful added benefit of Kegels is that the increased muscle tone can increase sexual pleasure in both sensation and orgasm. Male partners are happier too!

Sometimes women have trouble identifying the muscles that control the bladder and get frustrated attempting Kegels. This can be a natural result of conditioning the brain to ignore bladder stimulation. How many of us are too busy to go to the bathroom when we feel the urge, then “forget” we had to go. Over time, it’s possible that our brain just stops paying attention and we disconnect. It can take some work to get those pathways talking again.

If Kegel exercises don’t seem to be working well for you, you can try insertable cones or balls (available through your doctor or on the internet) to help you train your PC (pubococcygeal) muscle. Biofeedback practitioners use electronic monitors inside the vagina to help women learn how to identify and tone muscles related to the bladder. Both tools can be very effective.

Any kind of physical exercise that engages your core will help strengthen your pelvic muscles, but Pilates and yoga in particular are great inner toners. Both focus on building a firm core or root. They also use deep breathing and mindful movement to reconnect the brain to the body.

Acupuncture is another method that has provided symptomic relief for some women. It helps tone muscle and increase blood flow to the bladder. It can boost the immune system, soothe inflammation, and restore balance to the hormones.

Pelvic physical therapy (PPT) is sometimes effective in difficult cases. Practitioners use several diagnostic tools, including sonograms, physical exams and lower back screenings to evaluate the cause of incontinence. Treatment may include external and internal pelvic floor massage, relaxation training, biofeedback, strengthening, bladder retraining, and home exercises. This is especially useful when patients have adhesions or physical anomalies due to radiation treatment, injury or surgery. Many women who undergo PPT report increased libido and enjoyment of sex in addition to better bladder control.

Nutrition is vital to restoring a healthy balance to your endocrine and immune system, which in turn is important for maintaining muscle tone and preventing infection. Eating a diet of whole foods with plenty of fruits, vegetables, protein and some whole grains will promote adequate nutrition and help level out your hormones. Be sure to take a robust multivitamin/multimineral formula to support your body. And try supplements with cranberry extract — just be sure they don’t have added sugar.

Allergies may exacerbate an overactive bladder. If you think you may have food allergies or sensitivities, we recommend trying an elimination diet (avoiding a suspicious food for two weeks, then re-introducing it for a day or two).

Drink plenty of water and herbal tea. Flushing your urinary tract regularly will help evacuate bacteria. Cranberry juice and extracts can help prevent urinary tract infections by changing the pH of the bladder, but again, be sure you choose one with no added sugars. (Excess simple carbohydrates in the diet only encourage UTI’s).  If you are getting up in the middle of the night to urinate, stop drinking a few hours before bed.

Internal or surgical methods. If you’ve tried everything and you still can’t go out for an evening without worrying, you may want to consider a form of internal intervention. If urinary incontinence is keeping you from fully enjoying your work, love life, hobbies and pursuits, then fitted internal devices or surgical interventions are a reasonable next step.

Fitted pessaries, sometimes referred to as prolapse pessaries, are removable umbrella-like support rings that can help lift your pelvic organs up off your bladder. A pessary can be a great non-invasive choice for a woman with a cystocele or uterine prolapse.

New techniques like bladder laparoscopy and bladder slings can be helpful for treating severe stress incontinence in some women. Currently the most common procedures are known as the Burch colposuspension technique and the fascial sling. In the past, bladder suspension surgeries had a useful life of about four years. In the Burch, the urethra and bladder are secured with sutures to the pelvic wall. The new bladder slings use life-like materials that move with the body and act like real muscle.

Unfortunately, however, a study published recently in the New England Journal of Medicine suggests that neither of these surgical procedure offers terrific results for the women who have them. Known as the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr), the fascial sling was compared with the Burch colposuspension technique for treating stress urinary incontinence — the type of leaking that can occur when we run, laugh, sneeze, cough, or lift heavy objects. A mere two years following surgery, only 47% of the sling patients and 38% of the Burch suspension patients experienced good resolution of their stress urinary incontinence. Even so, the better results of the sling appeared to be offset by higher rates of UTI’s, problems with voiding, and even urge incontinence.

As with any surgery, we recommend getting as much information as possible and discussing your options with a few practitioners. More progressive doctors are using the latest technology to re-engineer a leaky bladder without excessive trauma and scarring. There are now gynecologists who specialize in urology (urogynecologists), and more women are going into urological surgery (formerly an exclusively male specialty). It’s safe to say that the more experience a surgeon has with a procedure, the more likely it is that you will experience the results you are looking for.

Emotional work. Understanding our hidden fears and anger or reluctance to “let go” can be a powerful remedy in dealing with incontinence. Many women have found relief with the Feldenkrais method — a mind-body technique that can help heal physical conditions through the release of emotional blockages with movement.

Because the brain and the bladder are intimately connected, it only makes sense to approach incontinence on both fronts.

Don’t just live with incontinence

I know there isn’t an easy remedy for urinary incontinence. Gravity, aging and loss of estrogen are pervasive. But like so many problems with our bodies, let’s focus on what we can control — because that’s how we’ll find solutions. I feel for every woman whose life is compromised by urinary incontinence. With a willingness to talk about it and experiment with changes, we so often see great improvement.