Don't make me laugh or I might pee my pants....

So what is leaking urine all about? Will it get better? Is there anything that can be done?

Let's start with the different kinds of urinary incontinence. There are two basic causes: first tissues can be stretched out and injured usually from childbirth (stress urinary incontinence- SUI). Second, there can be a neurologic problem where the bladder will squeeze even though your brain told it not to (Urge incontinence).

SUI is usually associated with childbirth-though it only takes one baby. Having a c-section lessens the risk of SUI but doesn't eliminate it as there is some stretching and nerve injury just from carrying a baby. It can also be caused from heavy lifting and just from having genetically relaxed pelvis. When you cough and sneeze you apply pressure to both the bladder and the bladder neck (the urethra). If the pressure is equal and the bladder neck has something to press against, the bladder neck should close off and you won't leak. If you have some relaxation of the vaginal wall, the bladder neck now has nothing to push against and it will leak. A good example is a garden hose. If you step on a hose on cement you can close it off and block the water. If you step on the hose on grass it is much more difficult to close it off.

Because SUI is an anatomical problem the treatment is to tighten up the tissues around the urethra or at least provide a "cement" foundation for it to sit on. Doing exercises to strengthen the muscles of the pelvic floor (kegels) can help some. This is done by flexing the muscles that would normally stop a stream of urine while you're urinating. If you are bouncing in your seat you are doing it wrong. If you want to put a finger in the vagina and try and squeeze it you will help you know that you are doing the exercise correctly. This is not for the faint of heart. You really need to do about 70 of these a day to start and then maintain with about 50 a day. That means every red light or every commercial you should be doing some.

Aerobic exercise will also make you flex the pelvic floor without hardly noticing it. You may leak initially, but as you do more exercises that require heavy breathing you will see your SUI is getting a little better.

Surgery is the usual mainstay for fixing SUI. This is often done at time of hysterectomy but can be done alone. Typically, the surgery will require an incision inside the vagina under the bladder. Some tissue will be brought under the bladder to hold it up and often a mesh will be placed to provide the "cement" needed to support the urethra. This surgery has a 85-92% "dry" rate in 5 years-meaning most women are very happy with it. The symptoms may occur years later as tissue stretch out again but the intent of the surgery is hopefully to never need surgery again. There are risks to the surgery. First, of course is just the surgery itself-risk of anesthesia, infection, bleeding etc. Second, you can have things heal too tight and have trouble emptying your bladder. This may require catheritizing for a few days or even weeks. You will almost always void a lot slower than before. Generally someone with SUI can be in and out of the bathroom in record time, after this surgery you will be the slow one that has to manuever on the toilet for awhile to be sure that all is empty. You may also get some urge incontinence (see below) after surgery from the inflammation and irritation. This usually improves over time but can always be there. Lastly, the mesh can erode into the vaginal wall or the bladder and my need to be trimmed or removed.

So when do you give up on kegels and have surgery. Because there are risks, I usually tell my patients that if they are giving up activities that they usually like-running, horseback riding, softball-it's time to get it fixed. Also, if you are wearing a pad everyday due to the incontinence you should probably get it fixed.

Will it get worse? We used to think that it would always get worse and so fix it now. There has been some new research though that shows some women will actually get better over time. If you have recently had a baby, I would wait a year or so to see if things improve (unless you were leaking before your got pregnant as well). If you just started leaking with a recent cough, I'd probably try the kegels and give it time to see if things will tighten up again as well. It has to be worth the potential side-effects before you have surgery. Having said that, women who leak all the time and have the surgery love it. It can really be life changing.

So what about urge incontinence. This is usually from a nerve "misfire". You brain will talk to your bladder and tell it that it's not time to squeeze but occassionally the bladder says, "I don't care" and squeezes anyway. If you have a really tight urethra this would just cause pain, but if you have any age to you, or injury, you will probably leak, and leak alot. Urge incontinence will usually make you void quite a bit of urine before you can control it again. Because this is a nerve problem it is usually treated with medication. The medications are very good but can give you some constipation and dry mouth at times as well. The medications work best when taken daily but I do have some patients that just take them when they are traveling long distances or for specific events. Cutting back on things that can irritate the bladder will help as well. Especially caffeine and soda. Cutting back on your overall fluid intake may also help-less than eight 8 oz glasses really is fine.

You can have mixed incontinence as well. You can have a little urge that will cause the SUI to be worse and visa versa. Women with both will often undergo urodynamic testing to evaluate what would be the best treatment options. Because surgery for SUI can make the urge incontinence worse, it would be worthwhile to see how much urge incontinence you already have.

There are a few other reasons for leaking that I haven't talked about as they are rare. If you are bothered by incontinence take a day or two to write down a journal of when you leak, what you were doing, and how much you leaked. This will help you and your physician decide what would be your best treatment.