by Maura Duffy
Urinary incontinence is the loss of bladder control, a condition that affects 13 million women in the United States . Stress incontinence, the most common type in women, is when leakage occurs during activities that put pressure on the bladder, such as coughing, sneezing, laughing, lifting, or running. These accidents happen when the muscles that contract to hold urine in (known as pelvic floor muscles) are too weak to handle sudden pressure on the bladder during “stressful” activities.
Though stress incontinence affects people of all ages, races, and both sexes, it is twice as common in women as in men; and affects one in three women at some point in their lifetimes . It is more common in women because pregnancy, childbirth, and menopause may weaken the pelvic floor muscles. The condition is especially common in older women because the pelvic floor muscles tend to weaken with age, especially when hormone levels drop after menopause.
If stress incontinence is affecting your lifestyle, there are treatments that can lessen the problem or eliminate it entirely. Although there are surgical devices such as bladder slings, mesh implants, and transvaginal tape that are approved by the FDA to treat urinary incontinence, they have very high rates of complications.
Mesh operations in particular, have been notoriously bad in both men and women. One study of mesh operations showed that 12-17% of patients were re-admitted to the hospital for hernias, and the majority of those patients had life-threatening complications solely from the mesh operation. These complications include bowel perforation, enterocutaneous fistulas, chronic surgical site infection, late intra-abdominal abscess, nonhealing wounds, hematomas, seromas, and bowel obstruction. Most of these complications required reoperation and seriously question the safety of these procedures .
As the implanted devices age, they have been known to cause chronic pain, nerve damage, scarring, and infection . Some women report being unable to have sex or even sit without pain. Several surgical devices have recently been withdrawn from the market because of lawsuits filed by women who have been seriously injured .
The good news is there are simpler and safer treatments that have been shown to improve bladder control and decrease stress incontinence. The treatment that has been shown to have the most consistent success in helping women achieve continence is pelvic floor muscle exercises that you can perform yourself at no cost . The fact that it is free is probably the reason it is not used more widely: nobody is advertising it because they can’t make much money from it.
Before you go to a doctor about your stress incontinence, here is information that will help you decide what kind of doctor or treatment is best for you.
The easiest first step is pelvic floor muscle training, done by performing Kegel exercises. Invented by and named after gynecologist Dr. Arnold Kegel, these exercises are performed by squeezing and holding the muscles you contract to stop yourself from going to the bathroom. A doctor can help you develop an exact regimen, but usually these exercises should be performed about twice daily, and they can be done almost anytime: while watching TV, sitting at a stop light, or working at your desk, for example . Research proves that consistent pelvic floor muscle training decreases stress urinary incontinence incidents . In a review of 905 studies, three out of ten women achieved full control of their bladder (continence), and an additional four out of ten reduced their symptoms by pelvic floor muscle training alone, making it the most successful treatment studied. There are no risks from Kegel exercises, but do not perform them while urinating or with a full bladder as this may lead to urinary tract infection.
If you are having trouble with Kegel exercises, there is help available. The biofeedback method involves an electrical patch that a therapist places over your bladder and links to a TV screen. You and your therapist can see on the screen when your pelvic muscles are contracting as you perform Kegel exercises, so you learn to identify the right muscle groups. There are no harmful effects from biofeedback, but there is no evidence that it will improve your bladder control more than Kegel exercises alone – unless you need the biofeedback to identify the muscles to exercise .
Vaginal cones (or vaginal weights) are another tool to help women increase pelvic muscle strength. While standing, the patient inserts the small metal cone like a tampon and then contracts the pelvic floor muscles to prevent the cone from slipping out, usually for about 15 minutes at a time once or twice a day. Research has shown that while vaginal cones are inexpensive and have no harmful effects, they are not more effective at reducing stress leakage than basic Kegel exercises.7
Just as your arms, legs, and abs do not instantly tone from going to the gym a few times, it takes time for pelvic floor muscles to strengthen enough to noticeably improve bladder control. Most women see a reduction in leakage after about six to twelve weeks of regular Kegel’s exercises, so be patient and stick with your routine.6 Though biofeedback and vaginal cones are not necessary, they are safe tools if you are having trouble with Kegel exercises.
For women who are overweight, reduction in bladder leakage is yet another health benefit of weight loss. In one study, 388 overweight and obese women were assigned to an intensive 6-month weight-loss program that included diet and exercise. Almost three quarters of the women who lost weight noticed a significant reduction in weekly number of incontinence episodes.¹ Though it is not known for sure why extra weight may exacerbate stress incontinence, some scientists believe that excess belly fat puts more pressure on the abdominal muscles, which in turn increases pressure on the bladder. Weight loss may reduce these extra forces on the bladder, resulting in fewer incontinence episodes.¹
Another way to strengthen the pelvic floor muscles is by electrical or magnetic stimulation. With electrical stimulation, a silicone rubber tube that is attached to a battery-operated unit is inserted into the vagina, similar to a tampon. A small amount of electricity is sent through the tube into the surrounding nerves causing the muscles to contract. This therapy, which can be done at home or in a doctor’s office, has a success rate similar to Kegel exercises and has no additional benefits, but costs much more.7
Magnetic stimulation is done in a doctor’s office with the woman sitting in a special chair that has magnetic coils. An electric current is sent into the coils, creating a magnetic field that tenses and relaxes the muscles of the pelvis. Research has shown that magnetic stimulating devices work as well if they are on or off, so there is no reason to spend money on these treatments.5,7
A pessary, also known as an intravaginal bladder neck prosthesis, is a stiff ring that a doctor or nurse will fit you for and insert into the vagina. The rigid ring, made out of latex or silicone, repositions the urethra, leading to less stress leakage. A pessary requires regular checkups with a doctor as it can increase the risk of developing urinary tract infections with complications. There are other disposable inserts that you can apply yourself, like urethral plugs and continence tampons. Two scientific reviews have concluded that there is not enough consistent evidence to show that pessaries and other disposable vaginal devices improve stress urinary incontinence.6,8 So again, Kegel exercises, which are proven to work, are a better option.
There are several drugs that are prescribed for stress incontinence but all have side effects and risks, and many don’t help at all. Estrogen, which is made under many brand names and can be taken in a variety of ways (orally, applied to the skin, or inserted in the vagina), may be prescribed for stress incontinence in post-menopausal women. This use is “off label,” which means it was not proven to work for stress incontinence. However doctors can still prescribe it for that. Studies have shown that low doses of vaginally administered estrogen—tablets, creams, rings—may improve stress incontinence symptoms for some women.8 Estrogen patches that you place on the skin, however, may worsen symptoms.8 There are health risks associated with estrogen, as there are with any post-menopausal hormone therapy.
Duloxetine, under the brand name Cymbalta, is an anti-depressant that some doctors prescribe “off-label” for stress incontinence. A review of clinical trials showed that duloxetine did not cure stress incontinence when compared to a placebo. Though some women did improve bladder control while taking duloxetine, many women experienced unpleasant side effects like dry mouth, nausea, and fatigue and discontinued taking it. In fact, more women stopped taking Cymbalta because of side effects than the number of women who noticed an improvement in bladder control.8
Another therapy involves injecting “bulking agents” to thickening the tissue around the urethra to better withstand the pressure that causes leakage. The bulking material varies: it can be carbon beads, calcium particles, bovine collagen, swine collagen, or silicon particles . Repeat injections every six to 18 months are usually needed because the body breaks down bulking agents over time.7 A scientific review of 14 clinical trials of various bulking agents that included over two thousand women reported that the only bulking agent to show an advantage over Kegel exercises was silicon particles.10 However, the follow-up for this trial was only three months, so it is not known if these results hold up in the long run or what the long-term risks are. Known side effects of urethral injections are urinary retention, painful urination, and pain or infection at the injection site.10 Given the lack of long-term data on the success of injection therapy and given the high cost of needing repeat injections, there is no reason to spend money on this type of treatment.
Renessa is the brand name for a procedure known as “radiofrequency collagen denaturation.” A probe is inserted into the upper urethra (near the bladder) and emits radiofrequency waves that generate heat, burning tissue in the urethra. When the tissue rebuilds itself and forms scars, it becomes firmer, which may decrease involuntary leakage . This procedure can be done in a doctor’s office in less than half an hour but requires anesthesia. The only published studies have been funded by the manufacturer of Renessa, and none have follow-up longer than 3 years, so it is not known what the consequences of burning urethral tissue are in the long run. It is also important to note that the FDA has only approved Renessa for women who have tried and failed at conservative treatments, meaning Kegel exercises . Harvard Women’s Health Watch recommends against Renessa because of the lack of independent studies on its safety and effectiveness.11
THE BOTTOM LINE
While stress incontinence may feel embarrassing or demoralizing, remember that it is a medical condition that affects millions of women, and it can be lessened or cured without invasive surgery. Since Kegel exercises are the simplest, safest, and most effective treatment, it should be tried first, but must be done regularly. In fact, Kegel exercises alone, when performed correctly, daily, and for at least six weeks are extremely likely to reduce symptoms. In the meantime, you can help reduce your symptoms by scheduling regular bathroom breaks, wearing an absorbent liner, or losing weight if you are overweight.
Updated in 2016
 Subak, Leslee L., et. al. “Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women.” The New England Journal of Medicine. 2009; 360:481-490. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa0806375#t=article.
 U.S. Department of Health and Human Services Office on Women’s Health. (March 2010). Urinary Incontinence Fact Sheet. Retrieved from: http://www.womenshealth.gov/publications/our-publications/fact-sheet/urinary-incontinence.cfm
 Kokotovic, D., Bisgaard, T., & Helgstrand, F. (2016). Long-term Recurrence and Complications Associated with Elective Incisional Hernia Repair. JAMA, 316(5): 1575-1582. doi:10.1001/jama.2016.15217
 FDA Press Release, July 13, 2011. Retrieved from: http://www.fda.gov/medicaldevices/safety/alertsandnotices/publichealthnotifications/ucm061976.htm
 Thomas, Katie. “Johnson & Johnson Unit to Halt Urinary Implants.” The New York Times. 5 June 2012
 Shamliyan, Tatyana A., M.D., et. al. “Systematic Review: Randomized, Controlled Trials of Nonsurgical Treatments for Urinary Incontinence in Women.” Annals of Internal Medicine. 2008.
 NIH. National Institute of Diabetes and Digestive and Kidney Diseases. National Kidney and Urologic Diseases Information Clearinghouse. “Urinary Incontinence in Women” NIH Publication No. 08-4132. October 2007
 Shamliyan T, Wyman J, Kane RL. Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness. Comparative Effectiveness Review No. 36. Agency for Healthcare Research and Quality. April 2012. Retrieved from: www.effectivehealthcare.ahrq.gov/reports/final.cfm
 Castro RA, Arruda RM, Zanetti MRD, Santos PD, Sartori MGF, Girao MJBC. Single-blind, randomized, controlled trials of pelvic floor muscle training, electrical stimulation, vaginal cones, and no active treatment in the management of stress urinary incontinence. Clinical Science. 2008;63:465-72
 Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD, McClinton S. Urethral injection therapy for urinary incontinence in women. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD003881. DOI: 10.1002/14651858.CD003881.pub3
 Robb-Nicholson C. By the way, doctor. I have stress urinary incontinence and don’t want to have surgery. What can you tell me about Renessa? Harvard Women’s Health Watch. 2009 Oct; 17(2):8
 Department of Health and Human Services. FDA Premarket Notification. 2 July 2005. Retrieved from: http://www.accessdata.fda.gov/cdrh_docs/pdf4/K042132.pdf