If the many health issues that come with aging, one of the most vexing is also among the hardest to talk about, even with a doctor: a troublesome bladder.
Now, researchers and doctors are mounting new efforts to erase the stigma, inform patients about the best treatment options—and prevent problems from starting in the first place by promoting better bladder health.
One-third of Americans 40 and older report suffering from urinary incontinence—the accidental leakage of urine—at least “sometimes,” according to the nonprofit Urology Care Foundation. By interfering with daily life, incontinence can cause emotional, psychological and social distress. It occurs twice as often in women, but also affects 1 in 4 men.
It’s no wonder that the adult-incontinence-product market is burgeoning world-wide, and that a growing number of treatments are available to manage bladder function. These include surgical procedures, implanted devices, injections of Botox and prescription drugs.
Yet many sufferers wait years before seeking care, if they seek it at all. Untreated, incontinence contributes to misery in old age, and is associated with falls and fractures, sleep problems, depression and urinary-tract infections.
“Every day, we see patients who say, ‘I’m too embarrassed to talk about this,’ and they are always shocked when we tell them how common it is,” says Donna Mazloomdoost, program director of the Pelvic Floor Disorders Network at the National Institute of Child Health and Human Development, which sponsored a new study that aims to improve how women are counseled and treated.
One of the most bothersome types of urinary incontinence is urgency incontinence, a symptom of overactive bladder, which happens when the bladder muscle spontaneously contracts, leading to a sudden and strong urge to urinate, even if the bladder isn’t full. Another type, stress incontinence, occurs when weak support around the urethra lets urine escape. This can happen during exercise, walking, lifting something or even after a sneeze, cough or laugh.
The causes vary by sex. For women, incontinence issues can start after pregnancy or chronic conditions that weaken the pelvic muscles and worsen over time. High-impact sports and vigorous activities are associated with stress incontinence in girls and women in their reproductive years, and menopause can bring on overactive bladder and incontinence. A 2018 poll conducted by the University of Michigan found nearly half of women over 50 experienced moderate to severe incontinence but two-thirds hadn’t talked to their doctor about it.
Stress incontinence is less common in men. But overactive bladder is more likely in men with prostate problems including prostatitis, a painful inflammation of the prostate gland, and benign prostate hyperplasia, an enlargement of the gland that can happen as men age. Incontinence is also a common side effect of radiation and surgery for prostate cancer, including overflow incontinence, which may result in a constant drip.
For both sexes, incontinence can result from diabetes, obesity, high blood pressure and lifestyle habits that directly affect the bladder. Researchers are also studying the role of the urobiome—communities of bacteria that live in the urinary tract and are unique to each person. Imbalances in the urobiome can be linked to common bladder issues and might help predict which patients will respond to specific treatments, says Linda Brubaker, a urogynecologist at UC San Diego Health, part of the University of California.
Often, lifestyle changes such as losing weight and quitting smoking can help stave off or ease bladder problems. Excess weight weakens pelvic-floor muscles, while smoking causes coughing that can also lead to bladder leaks.
“There’s a general lack of awareness about healthy bladder habits, but most people can be helped by using simple common sense,” says Dr. Brubaker. “Treat your bladder well by filling it in a kind way and then emptying it regularly,” she advises. Pelvic-floor strengthening using a technique known as Kegel exercises can strengthen muscles that control the bladder, and behavioral techniques such as suppressing the urge to run to the bathroom can help regain control over the bladder and suppress urgency.
Fluid intake—how much and what type—obviously plays a role. Caffeine and alcohol can be bladder stimulants, and it’s better to drink small amounts of fluid frequently than to drink nothing for four hours and then drink 16 ounces in 10 minutes.
Treatment for urgency incontinence may begin with prescriptions for behavioral and exercise techniques and medications for overactive bladder that work by helping the bladder empty more fully or tighten muscles to lessen leakage. Stress incontinence can also be treated with exercise, but when symptoms don’t improve in women, an outpatient surgical procedure to place a thin strip of mesh under the urethra, known as a sling, is commonly used to prevent leaks.
As many as half of women with incontinence have both urgency and stress incontinence, a combination that is especially tough to manage. Standard treatment guidelines suggest that surgery may worsen the urgency component, so doctors might not offer it as an option early on. However, a study of 480 women with mixed incontinence, co-authored by Dr. Mazloomdoost and published in September in the Journal of the American Medical Association, challenged that approach, finding that it may unnecessarily delay surgery that can help women with mixed urinary incontinence.
Women in the randomized study had either just the surgery or the surgery plus behavioral and pelvic-floor muscle therapy. After a year, both groups showed significant improvements. However, those who combined surgery and physical therapy reported fewer instances of incontinence and were less likely to receive additional treatment such as overactive-bladder medications, suggesting they had more quality-of-life improvement than the surgery-alone group.
Shirley Javery, 80 years old, says her doctor In Rhode Island suggested she take part in the study, led by urogynecologist Vivian Sung of Women & Infants Hospital and Brown University’s medical school there. Ms. Javery says she is in good health, walks several miles a day and swims. But in her 70s, she developed mixed incontinence. “Every time I sneezed, I peed all over myself, and I was always running to the bathroom,” Ms. Javery says. She hated the idea of wearing adult diapers, or putting a crimp in her style. She was in the group that had both surgery and pelvic exercises with behavioral therapy, and kept a diary of urinary frequency and symptoms. The results, she says, “have been awesome, and I can sneeze without peeing. I feel like I’m in my 20s again.”
Burden for men
For men with enlarged prostate which causes a weak urine stream or a constant need to pee, several types of medication either shrink the prostate, halt its growth or relax muscles, helping improve flow. For more advanced cases or those that don’t respond well to medication, surgeons continue to refine procedures to reduce or remove the enlarged part of the prostate to restore normal urinary flow.
Meanwhile, prostate-cancer-treatment techniques such as nerve-sparing robotic surgery aim to protect more of the area around the bladder when removing the prostate than traditional methods which can cause temporary or permanent incontinence.
“As surgeons, we try to minimize the damage to those structures,” says Ash Tewari, a prostate-cancer surgeon and chair of the urology department at the Mount Sinai Health System in New York. Dr. Tewari developed a technique to restore muscles after the prostate is removed, allowing for more rapid recovery of urinary control compared with other surgical methods, though some men may need additional procedures.
Dr. Tewari also advises men after prostate surgery and even those without prostate problems to adopt healthy bladder habits and do their Kegel exercises, telling them, “You will thank me when you are 85.”
Ms. Landro, a former Wall Street Journal assistant managing editor, is the author of “Survivor: Taking Control of Your Fight Against Cancer.” Email: [email protected].
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