Regaining Control of Your Bladder

Medications and surgery can cure urinary incontinence, but first try cutting back on fluids and exercising the pelvic floor.

From an early age, we learn to fend off the urge to urinate and instead "hold it" till we can get to a bathroom. But many people lose the ability to control when they urinate. In the brain-versus-bladder tug-of-war, the bladder seems to gain the upper hand. Often it's a matter of small leaks of urine now and then, but it's common for the problem to be a much bigger one, because of either the frequency of the leakage, the amount of urine that comes out, or both.

Incontinence is a common problem among younger women because vaginal childbirth can damage the tissues that support the lower urinary tract. Later on, age becomes a factor. In the United States, surveys show about one in every four women over age 60 has some degree of urinary incontinence. Fewer men are affected, although by about age 80, the prevalence is roughly the same in both sexes. Men catch up partly because urinary incontinence is associated with prostate problems and the procedures to fix them.

Incontinence can have direct physical consequences. When skin is frequently wet with urine, it can start to break down, creating fertile ground for inflammation and infection.

But the bigger problem tends to be the consequences of worry and embarrassment. People with incontinence problems may avoid going out, withdraw socially, and fall into depression. Many try to hide their problems from friends and family, and studies have found that about half of those with incontinence problems don't tell their doctors about it.

Living with urinary incontinence and keeping it a secret out of shame and embarrassment, while understandable, seems especially misguided because there is a good chance that it can be treated effectively — and often without medications or surgery.

Be thankful for bladders

We're not aware of it, but our kidneys are working all the time, filtering blood and making urine in the process. The normal output is several ounces of urine every hour, so it's a good thing that the lower urinary tract comes equipped with a bladder capable of storing some of that urine; otherwise, we'd be going to the bathroom all the time. A normal, healthy adult bladder can hold 13 to 16 ounces of urine before the urge to urinate becomes uncomfortable.

As urine flows into the bladder, the walls expand (the bladder is often compared to a balloon), and the sphincter muscles that control the opening into the urethra constrict, creating a tight seal so urine can't escape. As the amount of urine increases and the bladder expands further, stretch-sensitive nerves in the bladder wall trigger the micturition reflex: the muscle that forms the bladder wall contracts, the urethral sphincter muscles relax so the bladder neck and urethra open, and urine flows through the urethra and out of the body. This happens automatically; it's a reflex that's controlled by nerves and the "lower," unthinking parts of the brain. Infants don't have any control over this reflex, but early on, higher centers in the brain learn to depress and delay it, as well as turn it on, so adults do have quite a lot of conscious control over urination. Urinary incontinence is, by definition, loss of that control.

Three main types

Doctors have grouped urinary incontinence into categories based on the underlying cause. Here are the three most common types:

Stress incontinence. Stress incontinence doesn't have anything to do with feelings we have when we are busy or overwhelmed. A better name might be pressure incontinence. Coughing, laughing, or moving in certain ways (lifting something heavy, for example, or jumping) creates extra pressure within the abdomen, and that pressure pushes down on the bladder. Normally, the sphincter muscles around the urethra compensate for the extra pressure by tightening up. But urine can leak out if they can't squeeze tight enough. That can also happen if the muscles of the pelvic floor are lax. The pelvic floor is made of muscles and ligaments that extend like a hammock from the pubic bone in the front of the abdomen to the tailbone in back. If it's slack, the urethra doesn't have anything to be compressed against as the bladder is pushed down.