Although urinary incontinence is often thought of as a problem that only affects the very old, many women between the ages of 40 and 60 experience this frustrating and sometimes embarrassing problem. Most women in this age group have what is known as stress urinary incontinence, which is the involuntary loss of urine that can occur during activities such as walking, or when a person coughs or laughs. Although this condition may seem like a minor annoyance, a recent study reveals that more and more of these women are undergoing surgery to treat their stress incontinence. This study, published in the April 4 issue of Obstetrics and Gynecology, showed that rates of these surgeries among US women increased by 45 percent between 1988 and 1998.

This jump may reflect heightened awareness of stress incontinence among physicians and patients, says lead study author Dr. L. Elaine Waetjen, an assistant professor in the Department of Obstetrics and Gynecology at University of California, Davis. But Waetjen points out that there are many other effective treatment options besides surgery. Because stress incontinence is partly due to a weakening of the muscles that support the bladder, pelvic muscles can be strengthened with exercises taught by trained physical therapists and others. Additionally, women can use devices that block urine and practice behavior modification techniques.

Below, Waetjen explains stress urinary incontinence and its treatments.

What is stress urinary incontinence and how is it different than urge incontinence?
Incontinence is a medical condition; it is not part of normal aging, nor is it a common result of childbirth. Stress incontinence is basically loss of urine in the context of an increase in abdominal pressure. This means that when you cough and sneeze, you leak. With urge incontinence, the muscle around the bladder contracts inappropriately, forcing the urine out.

Who is at risk for stress urinary incontinence?
There are very few studies that separate out risk factors for the different types of incontinence; most look at stress and urge together. The studies that do look at stress incontinence show that age, childbirth and obesity are probably the strongest risk factors. Most women are between 40 and 60, whereas urge incontinence occurs in women who are older.

Smokers and people with chronic lung disease may be at increased risk because of a chronic cough. And people with collagen diseases—collagen is the primary component in connective tissues such as skin and tendons—are at increased risk. This may be because they don't have strong enough collagen to support the urethra, which is the tube through which urine flows out of the body.

What are some non-surgical treatments for stress incontinence?
There are a number of treatment options that can be tailored to meet the needs of different patients. One of the initial treatments for stress incontinence should be physical therapy. The idea is to teach women to isolate the pelvic floor muscles to increase their bulk and strength, as well as the coordination of these muscles. In some studies, up to 70 percent of women who are taught these exercises and do them will then not elect to have any further treatment.

There are different ways of teaching women how to contract those muscles. Sometimes a verbal explanation is given, and other times the health professional guides women through touch. The third method is using biofeedback, which allows the woman to learn to isolate the right pelvic muscles so they are not contracting other muscles, such as the abdominal muscles, at the same time. Biofeedback involves either putting electrodes on the skin or a probe inside the vagina. The electrodes are then hooked up to a monitor, and women can see on the screen if they are actually contracting the appropriate muscles.

How long is therapy usually given for?
It varies, depending on the severity of the incontinence. I usually send my patients for four to six weeks with a physical therapist doing biofeedback.

Do women know that physical therapy is an option?
I think that as more is learned about incontinence, and as people realize that this is a good treatment for a lot of women, more women are getting referred, either to health professionals who do biofeedback, or to physical therapists who use biofeedback or other methods. The problem is that there are not a lot of physical therapists, nurses or other health professionals who specialize in this therapy. So, women who live in rural areas, for example, usually have to drive to a fairly major metropolitan area.

What are other treatments for women with stress urinary incontinence?
Behavioral therapy, including limiting fluid intake and, for obese women, weight loss, can ease or treat some incontinence, and should be one of the first incontinence treatments. In addition, pessaries, which are like diaphragms that sit inside the vagina, are effective for some women. The idea is that when women cough and sneeze, their urethra gets pressed against this pessary and that helps prevent leakage. There are other devices that are basically like plugs. The one I recommend to my patients is a catheter that you put through the urethra into the bladder to block the urine. You can only leave it in for four hours at a time, but it can be helpful for some women, such as those who only leak when they exercise. Similarly, there are devices you can put over the urethra that collect the urine in case you leak

What were the most common types of surgery, according to your study?
About 70 percent of all stress incontinence surgeries were done in combination with other major gynecological surgery. The most common stress incontinence surgery was called a retropubic suspension, an abdominal surgery in which the tissues near the bladder are attached to the tissues of the public bone. This procedure has the longest track record and the best evidence for efficacy. So it's good news that most people were getting that surgery. The second most common surgery was the anterior repair, which involves an incision in the anterior wall of the vagina. The bladder and urethra are tucked up, and the tissue around the urethra is tightened. In studies over the last decade, that surgery was shown to be less effective and less durable than other surgeries. At five years, the rate of significant improvement in incontinence was only about 50 percent to 60 percent. By the same token, it is the surgery that most general OB/GYNs are trained to do and are comfortable with. It's also the least invasive surgery, so recovery is much quicker. Our speculation was that these are the reasons why anterior repairs were still being performed regularly.

The sling procedure was also relatively common. In this surgery, a strip of tissue is placed under the urethra. The average age of women undergoing this procedure was older. Although our study doesn't prove it, this may be because slings have traditionally been used after previous surgery has failed or when the urethral sphincter (muscle) doesn't work well, which is a more common problem in older women.

Why do you think the rates of surgery have gone up so much?
I think it's hard to sort out. More researchers are interested in the problem, and the studies are getting better at identifying risk factors for incontinence. As a result, awareness among both physicians and patients is increasing. So maybe with new information out there, women are more willing to come forward with their incontinence and physicians are asking patients about it more often. Additionally, as the population ages, conditions that are common in older women are getting extra attention.