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by Joan Kenly, Ph.D. with John C. Arpels, M.D.

Incontinence difficulties can erode your confidence and chip away at your self-esteem. How can you be yourself if you're constantly worried about the possibility of an embarrassing accident? You may feel you can't talk to your doctor about this "indelicate" subject. So you literally grin and bear it and put your life on hold.

If you feel a frequent urgency to urinate, and maybe leak when you laugh or sneeze, you are not alone. This is an important concern to address. The urinary frequency and incontinence symptoms that you are having are also bothering more than ten million other Americans-mostly women-to a greater or lesser degree.
     Urinary problems can strike women at any age because of the effects of childbearing or the position of the uterus. Other considerations are the way women are built inside, diseases, infections, or weakness in the bladder and urinary tract.
Many times the difficulty is caused by a decrease in estrogen.
     Here are several types of urinary incontinence affecting bladder control:

     1) Urge incontinence. The loss of bladder control stemming from various causes. Conditioned responses and bladder spasms can be triggered by various situations. An ordinary trigger, for instance, is the sound of running water. Urge incontinence can also be caused by infection of the urinary tract, estrogen decline during menopause, bladder inflammation, injuries to the spinal cord, pelvic irritation, spinal nerve-root problems, and chemotherapy. It is characterized by a powerfully urgent need to urinate, with loss of urine when one cannot reach the bathroom in time.
     2) Stress incontinence. The leaking of urine when coughing, laughing, sneezing, or lifting puts pressure on the bladder. This stress response in the bladder can be affected by some of the conditions mentioned above. This is the most common urinary problem reported.
     3) Overflow incontinence. Urine leaks out when bladder is too full, though with no perceived sensation to urinate. This is often due to diabetes or spinal cord injury.
     Sad to say, a great number of women continue to have these difficulties because they are embarrassed or ashamed to get help. And help is available. I hope more women will be willing to talk about incontinence as millions of baby-boomer women sweep into mid-life together. Whether you leak urine when you laugh, cough, or sneeze, have to go to the bathroom every hour, or ever lose control, be aware that:

- your estrogen levels may be low;
- the amount of collagen in your tissues could be decreasing;
- your bladder may have shrunk;
- your bladder may be having spasms;
- your pelvic floor muscles have become weaker;
- you could have a vaginal or urinary tract infection;
- you may have bladder cancer (although this is rare);
- certain commonly used medications can cause bladder problems,
   i.e., antihistamines, tranquilizers, and blood pressure medications; and
- spicy foods and caffeine beverages can affect bladder control.

Any or all of your incontinence difficulties, if not caused by major illness; injury; or structural conditions, can be greatly improved with certain estrogen treatments, exercises, or behavior modification. ( As a last recourse, choose antispasmodic drugs or surgery.)
     Estrogen replacement therapy, topical estrogen at the urinary opening, or vaginal estrogen inserts such as tablets, suppositories, or the ninety-day vaginal ring sold under the brand name Estring.
     Biofeedback training clearly helps to retain certain muscles for effective urinary control. To attain the most efficient results, incontinence clinics and some urologists' offices offer this technology along with Kegel exercises, detailed next.
     Kegel exercises. A recent study supports the premise that strengthening the pelvic muscles can reduce stress incontinence by 50 to 90 percent. These exercises can build up the muscles in the pelvic floor that manage continence and help you regain bladder control. Here's how to do them:

1) Squeeze in the muscles that you use to hold back urine and to contract your vagina.
2) Hold each contraction for the count of three seconds.
3) Release slowly and relax for three seconds. The release is as important as the squeeze. The goal is muscle  function as well as strength.
4) Repeat contractions and release in groups of three many times daily. Try this routine for several days just to get used to it.
5) Increase number of repetitions as you also prolong the amount of time you hold and release, based on a timing that's workable for you — e.g., five times and five seconds. Then if you can, work up to holding for ten seconds with the number of repetitions per day that will fit your own comfort level.
6) Observe your results. Consult with your health advisor as to how many contractions each day may be the control point for you to reach your personal continence goal. However, with biofeedback methods available at some clinics and hospitals, you will know with greater certainty that you are performing the exercises with the correct muscle groups.

By the way, there's a bonus. Kegel exercises will not only help control urinary problems , but they'll give you the added dividend of increased sexual pleasure. The resulting responsiveness of these muscles can enhance your orgasms.
     Collagen therapy has been recently approved by the FDA for stress urinary incontinence. It's a hardy, fibrous, common protein found in our bodies, and it holds tissues and cells together. It is medically used in various therapies when appropriate. Since 3 percent of people tested have an allergic reaction to collagen, a four-week skin test is needed before the procedure is used. Peggy Eastman, writing for the AARP Bulletin, explains that "collagen, administered under local anesthesia in a doctor's office, adds bulk to the urethra, thus increasing its resistance to leakage. The procedure is intended for people who've had incontinence for twelve months with no improvement from other therapies [such as Kegel exercises or hormone replacement], and [the patient] should be injected only by doctors who specialize in incontinence."
     Liquid intake is more favorable if you drink the major amount of your daily consumption before six o'clock. Then only sip sparingly during the three hours before your bedtime. Also, emptying your bladder every two to three hours is very helpful. Many women tend to hold urine too long for their health and comfort. The less pressure in the bladder, the less stress loss will occur.
     Avoid or reduce your consumption of alcohol, caffeine, chocolate, acidic or spicy foods, citrus, tomato juice, and Nutrasweet or any other aspartame sugar-substitutes. All these can irritate your bladder and compound the intensity of any bladder or urinary tract symptoms.
     For managing incontinence until any treatments or exercises are successful, consider this: some of the largest sanitary pad manufacturers are "remarketing" the design of their pads to appeal to women in midlife and older years to protect against accidents from incontinence. Various brands are easily available. You've probably seen them advertised. However, don't let these pads become a crutch. If your incontinence does not need surgical repair, there is a very good chance that the Kegel exercises can be an effective, inexpensive way for you to be worry-free from your problem.

From Whose Body is it Anyway?, by Joan Kenly, Ph.D. with John C. Arpels, M.D. Copyright 1999 by Joan Kenly. Excerpted by arrangement with Newmarket Press. $24.95. Available in local bookstores or click here.