After age 40, as many as one out of six—or more than 12 million American women-may experience uncontrollable loss of urine. Many more women are troubled by the condition than men. But for most, incontinence is a highly treatable condition, though it may not always be addressed. Half of nursing home residents (mostly women) are affected by some type of incontinence.

Why Do We Become Incontinent?

Urinary incontinence is common, and can result from anatomic, physiologic or disease factors. Incontinence should not be thought of as a consequence of aging, according to experts. It sometimes affects even the young, for a variety of reasons. Temporary incontinence is commonly caused by childbirth, limited mobility, urinary tract infection, or medication side-effects.

For millions of Americans, incontinence affects their emotional, psychological and social well-being. Many curtail social and recreational activities, and are reluctant to do things they used to in case a restroom is not nearby.

Types of Incontinence

There is more than one type of incontinence. "Stress incontinence is a common condition in which urine leakage occurs when a woman coughs, sneezes or laughs," says physical therapist Mary Russell, who teaches a two-hour class on incontinence at the John Muir Women's Health Center in Walnut Creek. "It can also be experienced as a sudden sense of urgency to urinate. Women shouldn't hesitate to seek treatment. There is a lot to learn about physiology, and much can be done to improve the condition. About 75 percent of women with this problem who follow some simple steps can get better without surgical intervention."

Among the recommended strategies are pelvic floor exercises, dietary changes, weight loss when indicated, avoiding constipation, and use of vaginal estrogen supplementation for women past menopause. Women can learn to use their pelvic floor muscles functionally throughout the day to re-establish effective muscle tone, and exercises can be tailored to individuals, Russell says. "Just as you've learned to cover your mouth when you sneeze, you can learn to have your pelvic muscles work fast enough and strong enough to prevent leaking."

Pelvic Anatomy

Understanding anatomy helps to illustrate how incontinence develops. The pelvic floor is a sling of muscles like a hammock supporting the bladder, vagina and rectum. When the pelvic floor develops laxity, any abdominal pressure on the bladder overcomes the muscles. When you strain, it can cause damage to the pelvic floor muscles so they can't work as well.

Judson Brandeis, M.D., a urologist on staff at John Muir Health, emphasizes the importance of beginning Kegel exercises early in a woman's life. These are the muscles you squeeze to stop the flow of urine. Performing these exercises several times a day, especially beginning after vaginal childbirth, can improve urinary, vaginal and rectal tone. They can be done without being noticed, while stopped at a traffic signal or during a TV commercial break, he suggests.

Additional nonsurgical devices can be used: vaginal cones can help identify muscles that need strengthening and help to work them. A probe used during biofeedback can measure pressure exerted during muscle contractions. A pessary, a device that looks like a ring, can be used for nonsurgical candidates. Placed around the cervix, it and a small attachment hold up the bladder neck above the pelvic floor. In another technique, an injection of collagen or similar substance can be given at the bladder neck to narrow the opening of the bladder. Medications may also be prescribed to increase internal sphincter tone and bladder outflow resistance when appropriate.

When Surgery is Needed

Sometimes a woman's incontinence progresses beyond the scope of the interventions that Russell teaches. "One in every nine women has a surgical procedure for incontinence during her lifetime," reports Dr. Brandeis. "Reasons for surgery can include a prolapsed uterus, or a condition in which another organ or internal structure sags into the vaginal passage and must be repositioned. A cystocele—a failure of support for the bladder—can also develop from small tears or poor muscle tone."

"The most effective procedure when Kegels don't work any more is positioning of a pubo-vaginal sling," Dr. Brandeis says. "This bladder neck suspension is an outpatient procedure with minimal pain and side effects that is highly successful and takes half an hour to perform. The correction can last a lifetime. The average age of women undergoing this surgery is between 40 and 85, depending on their general overall health. The same surgery can fix other structural problems as well."

Dr. Brandeis and others agree that the good news is that incontinence is highly correctable-and possibly preventable—if Kegel exercises are used to start training the pelvic floor before problems occur.