For Stacy Braun, having a baby changed her life, but in ways she did not expect.
The day after the Maylene, Ala., woman gave birth, she accidentally urinated on the floor. Despite her obstetrician telling her it is common for new mothers to have some loss of bladder control–known as urinary incontinence or UI–the problem did not go away. Five years and two surgeries later, Braun said she still cannot control her bladder. Any physical exertion that puts pressure on her bladder, such as coughing or lifting, causes her to leak urine, a form of UI called stress incontinence.
“I can’t go without wearing pads, or I will soak my underpants,” Braun said.
Stress incontinence also affects Deborah Margerum, a Philadelphia mother of three. Before she had surgery recently, activities such as climbing stairs and running with her dog could cause involuntary urination.
“I couldn’t do the things I wanted to do, because urine would leak,” said Margerum who first noticed the problem at age 40. Although Margerum’s incontinence improved after surgery, Braun said hers still bothers her every day. It caused her to stop working and exercising, resulting in weight gain and depression.
“I ask myself why this happened to someone as young as me,” the 28-year-old said. “Most people think only old people get incontinence, but that’s not true. Young mothers get it, too.”
The truth is, UI happens to a lot of mothers, especially after a vaginal delivery. Of the 3 million U.S. women who have vaginal deliveries each year, up to 30 percent will develop urinary incontinence, according to Dr. Roger Goldberg, an expert in women’s bladder problems and author of “Ever Since I Had My Baby” (Three Rivers Press, $16), a new book dealing with physical aftereffects of childbirth. Goldberg, a urogynecologist with Evanston Northwestern Healthcare, said women are at higher risk than men of UI.
Nearly 85 percent of the estimated 12 million to 25 million Americans with bladder control problems are women. Causes of UI include age-related dropping of the bladder, menopause, obesity and surgery such as a hysterectomy. But vaginal delivery is the leading risk factor, according to the Association of Reproductive Health Professionals.
“Vaginal delivery wreaks havoc on the pelvic floor,” said Dr. Kristene Whitmore, a urologist specializing in female urology and chairwoman of the urology department at Philadelphia’s Graduate Hospital. The pelvic floor supports the bladder and bowel and, in women, the uterus. Pregnancy and vaginal childbirth can weaken or damage the pelvic floor muscles and nerves that control the bladder, causing UI, and can sometimes displace the bladder. In addition, the urethra, the bladder outlet tube, leaks when it becomes too mobile due to pregnancy-related anatomical changes or becomes too thin.
Bladder problems occur up to five times more often after vaginal delivery than Caesarean section, Goldberg said. Factors during vaginal delivery that further increase the risk of UI include use of forceps; an episiotomy, a surgical cut in muscle to prevent vaginal tearing during delivery; birth of twins or other multiples; and delivery of a large baby.
Two of Margerum’s children weighed over 12 pounds at birth. Both Braun and Margerum had episiotomies and forceps-assisted deliveries. Their childbirths left them with the most common type of UI.
In women with UI, almost half have stress incontinence, Whitmore said. Just over one-fourth of women have urge incontinence, and the remaining women have both types, called mixed incontinence. Whereas people with stress incontinence have urine leakage after exertion, such as laughing, sneezing or sexual intercourse, those with urge incontinence get a sudden strong urge to urinate, followed by an uncontrollable release of urine. Women with urge incontinence may need to use the bathroom frequently; thus, this type of incontinence is also called overactive bladder.
Although UI after childbirth can be temporary, it becomes a long-term problem for large numbers of women, Goldberg said. Even if incontinence goes away, it may return.
“People who have incontinence problems temporarily after childbirth tend to have the problem recur when they get older,” said Teri Elliott-Burke, a physical therapist at Lake Zurich-based Women’s Physical Therapy Institute, which has a bladder control program.
Elliott-Burke said the sooner a woman with UI seeks help, the better. Goldberg recommended that women still experiencing urine leakage three to six months after delivery seek medical help, or sooner if the problem is bothersome.
Unfortunately, many women with UI suffer in silence. A December 2002 survey by the National Association For Continence showed that 37 percent of women with symptoms of overactive bladder did not inform their doctor of their symptoms. Other estimates are that 4 of 5 people with UI do not see a doctor about it.
Margerum said she waited years before seeing a urologist because she did not know UI is treatable. In fact, new treatment options have improved success rates in treating bladder control problems. Treatment can cure or improve UI in about 80 percent of people who have the condition, the NAFC reports.
Some women with UI put off going to a doctor because they fear they will need surgery, Gold-berg has found. However, many non-surgical treatments of UI exist, and surgery is becoming much less invasive. Help is available even for women with longtime incontinence.
“Women shouldn’t worry that if they wait, it’s not curable,” Goldberg said.
The initial treatment of incontinence typically is behavioral modification, which includes avoiding bladder irritants. Among the foods and beverages thought to contribute to bladder leakage are coffee and tea (even decaffeinated), carbonated and alcoholic drinks, chocolate and artificial sweeteners.
A do-at-home therapy, which has been around for decades, is Kegel exercises. These strengthening exercises involve repeated contractions of the pelvic floor muscles, located between the pubic bone and tailbone. Pelvic floor exercises performed during pregnancy also may reduce the risk of UI, a February 2003 study found.
The problem with Kegel exercises, Elliott-Burke said, is that “women often don’t know if they’re doing them right.”
It may be helpful to visit a health-care professional to learn how to properly do Kegel exercises. Devices, such as biofeedback, can show a woman whether she is exercising the right muscles or, in the case of pelvic floor electrical stimulation, can stimulate the muscles for her.
There is also a new electrical stimulating device that is surgically implanted under stomach skin for treatment of overactive bladder. It acts as a pacemaker for the pelvis, constantly stimulating the pelvic nerves.
If the idea of a pelvic pacemaker is not odd enough, there are collagen injections for UI. Cow collagen–the same substance used to plump lips and smooth wrinkles–or other bulking material can be injected into a thin urethra for short-term relief of stress incontinence.
“It’s not for everybody, but when it works, it’s a quick fix,” Goldberg said. “A woman can walk into [the doctor’s] office incontinent and walk out dry.”
Various oral medications and a medicated patch are available to treat urge incontinence, but stress incontinence often does not benefit from drugs. That may change. Whitmore said an antidepressant called duloxetine is expected to be approved by the U.S. Food and Drug Administration next year for treatment of stress incontinence, and preliminary results look promising.
“It will give people another option before surgery,” she said.
Surgery may become necessary when other treatments of stress incontinence fail. Some newer surgical procedures offer a cure rate near 90 percent. In the past, at least one-third of women with UI required more than one incontinence surgery, Whitmore said.
Braun plans next year to have her third surgery. “I’m willing to try anything” to get better, she said.
Margerum, now 48, had her first surgery in July and reports much less urine leakage now.
“I ran with my puppy for the first time today since before the surgery, and I was dry after the run,” she said. “I’m very hopeful.”
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Get informed about UI
– American Foundation for Urologic Disease
800-242-2383
www.incontinence.org
– American Urogynecologic Society
202-367-1167
www.augs.org
– American Urological Association
410-727-1100
www.urologyhealth.org
– National Association for Continence
800-BLADDER (800-252-3337)
www.nafc.org
– National Bladder Foundation
203-526-3169
www.bladder.org
– National Kidney and Urologic Diseases Information Clearinghouse
800-891-5390
http://kidney.niddk.nih.gov
– The Simon Foundation for Continence
800-23-SIMON (800-237-4666)
www.simonfoundation.org
