Rx for Change: Mentioning the Unmentionable: Urinary Incontinence (UI)

By Nancy Worcester and Mariamne Whatley

Urinary incontinence (UI) is finally something women can talk about—and do something about.  A new comprehensive study and a national meeting of UI researchers and other experts demonstrate widespread agreement that Kegel exercises and bladder training can improve UI symptoms for many women.[i] It’s time to make UI a topic for women’s health activism!

UI is prevalent, negatively impacts women’s lives, and has a range of treatment options—including some that are free, health promoting, without side effects, and very effective in improving symptoms and even “curing” UI. Yet, many people with UI fail to get help because their health care provider lacks the time, incentives, or training to address this issue.  Instead of being informed about safe, effective treatments, consumers are bombarded by advertising and information about money-making products and procedures that have negative side-effects, health risks, and may not actually treat UI.

People of all ages and genders can experience UI. The condition impacts 25% of reproductive age women, 50% of post-menopausal women, and 35% of men aged 65 and older.[ii] Among women over age 65, 54% report having “any” UI; of whom, 12% report their UI is severe, and 32% that their UI is moderate or worse.2

According to a longitudinal study of 40-65-year-old women reporting UI, 61% did not seek treatment. The most frequent reasons were: “UI not bad enough” (73%); “UI is [a] normal part of aging” (53%); and health care “provider never asked” (55%).2

Despite these statistics, a new systematic review and meta-analysis of UI studies confirms that there are simple and safe actions people can take to relieve UI.1 [iii] The assessments reinforce that behavioral approaches (i.e., Kegel exercises and bladder training) are effective and should be considered the first line for addressing UI.1 4 Professional organizations have consistently recommended this approach. The Women’s Preventative Service Initiative (https://www.womenspreventivehealth.org/) endorses UI screening for all women; screening guidelines like this are an important first step in addressing a health care issue because they encourage health providers to learn more about the topic and provide an indication to patients that their health providers are ready to discuss the topic, as well.2

Kegel exercises—which involve contracting, holding, and then relaxing the muscles that stop urine flow—are important in strengthening and maintaining pelvic floor muscles.[iv] [v] If pelvic floor muscles are weak, it’s harder for the sphincter (the muscle surrounding the urethra that controls urine flow) to prevent urinary leakage when there is intra-abdominal pressure. The systematic review and meta-analysis found that Kegel exercises improved symptoms in almost three-quarters of women with Stress UI, which is usually caused by weak pelvic floor muscles.[vi] Strengthening pelvic floor muscles can correct this problem, reducing Stress UI symptoms.

Kegels are easy to learn; don’t take much time, so they can fit into daily routines; and are inconspicuous, enabling people to perform them in a variety of settings. Lifelong daily Kegels can maintain pelvic muscle strength and reduce UI risk. Kegels should not be done while urinating, although initially doing so may help identify these muscles. Even though many people learn to do Kegel exercises on their own, it is helpful to get instructions on technique, frequency, quantity, and any specific concerns from a health practitioner like a physical therapist.

Bladder training is confirmed to be another effective first-line treatment, improving symptoms in more than three-quarters of women with Urgency UI.8 Bladder training involves developing a schedule for urination and then gradually increasing the time between urination, so the body adjusts and can hold urine longer.

Because there are no financial incentives for doing so, the health system could be much better at encouraging people to do pelvic exercises and bladder training to prevent or improve UI. So, it’s ironic that UI is a huge money-maker for UI product corporations. The worldwide adult UI market is rapidly expanding, from $5.7 billion in 2010 to 9.3 $billion this year, and is predicted to rise to $16 billion by 2024.[vii] [viii]

Using disposable UI absorbency products (pads, briefs, pull-ups) is the most prevalent strategy to manage UI, with around three-quarters of women with UI using such products daily.[ix] [x] These products range in type, quality, and cost, so women try a number of them and rely on information from retail outlets and advertisements, rather than getting advice and information from a health provider, which many would prefer.11 Many women use disposable menstrual pads for light UI, although these pads are designed to absorb slow blood flow, while UI products can better absorb rapid urine loss.10 11

These absorbent products must be changed regularly and used with caution to prevent both UI-associated skin problems and the risk of urinary tract infections (which can be caused by organisms from the vagina or rectum getting moved to the urethra or bladder).[xi] 13 The environmental costs of disposable UI products may be significant, as well. (While there has not been research on washable vs. newer disposable UI products, related research on baby diapers suggests there is no significant difference in the environmental impact of disposable diapers compared to home- or commercially-laundered diapers.[xii])

In advocating for more attention to be paid to bladder health, it’s time to ask what price women and the environment pay for daily use of disposable products that do nothing to improve UI. It would be more effective for women, and better environmentally, to promote free, effective, and risk-free Kegels and bladder training. The most urgent cost to think about is whether using absorbent products contributes to women not prioritizing effective treatment for their UI.

 

NOTE: We acknowledge the important work done by the Patient-Centered Outcome Research Institute (PCORI, www.pcori.org) and the Agency for Healthcare Research and Quality (AHRQ, https://www.ahrq.gov/) on UI. PCORI supported the systematic review by Balk et. al.[i] 1 in partnership with AHRQ. We also thank PCORI for inviting us to the June 25, 2019 PCORI/AHRQ Urinary Incontinence Stakeholders Meeting, which provided invaluable research and discussions and inspired us to write this article.

 

Balk EM, Rofeberg VN, Adam GP, et al, “Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women,” Ann Intern Med 2019; 170: 465-479.

Agency for Healthcare Research and Quality, “Non-surgical Treatments for Urinary Incontinence in Women,” (Nomination 3392, reviewer Huppert J), Appendix B-1. AHRQ, Rockville, MD. January 7, 2019. Material provided in preparation for June 25, 2019 PCORI/AHRQ Urinary Incontinence Stakeholders Meeting.

Patient-Centered Outcomes Research Institute, “Quick Look for Clinicians:  Nonsurgical Treatments for Urinary Incontinence in Women” PCORI, Washington, DC, September, 2019. Retrieved on October 4, 2019 from: https://www.pcori.org/research-results/putting-evidence-work/evidence-updates/treating-urinary-incontinence-women-without

MedlinePlus Medical Encyclopedia, “Kegel Exercises – Self-care,” National Institutes of Health/US National Library of Medicine, Bethesda, MD: 2019. Retrieved October 4, 2019 from: https://medlineplus.gov/ency/patientinstructions/000141.htm

Cooper L,  “Kegel Exercises and Other Bladder Control Tips That Work,”  Consumer Reports 2019, https://www.consumerreports.org/women-s-health/kegel-exercises/ Retrieved September 30, 2019.

Patient-Centered Outcomes Research Institute, “Evidence Update for Women: Treating Urinary Incontinence in Women Without Surgery,” PCORI, Washington, DC, September, 2019. Retrieved on October 4, 2019 from: https://www.pcori.org/research-results/putting-evidence-work/evidence-updates/treating-urinary-incontinence-women-0

Alam PA, Huang JC, Clark BA, et al, “A Cost Analysis of Icon Reusable Underwear Versus Disposable Pads for Mild to Moderate Urinary Incontinence,” Female Pelvic Med Reconstr Surg 2018;00: 00-00.

Market Watch, “At 9.5% CAGR, Urinary Incontinence Products Market Size Is Expected to Exhibit 16000 Million USD in 2024,” March 26, 2019. Retrieved September 29, 2019 from: https://www.marketwatch.com/press-release/at-95-CAGR-urinary-

Gray M, Kent D, Ermer-Seltun J, et al, ”Assessment, Selection, Use, and Evaluation of Body-Worn Absorbent Products for Adults With Incontinence,” J Wound Ostomy Continence Nurs. 2018; 45(3): 243-264.ith N, Hunter KF, Rajabali S, et al, “Where Do Women With Urinary Incontinence Find Information About Absorbent Products and How Useful Do They Find It?” J Wound Ostomy Continence Nurs. 2019; 46(1): 44-50.

Falloon SS, Abbas S, Stridfeldt C, et al, “The Impact of Microclimate on Skin Health With Absorbent Incontinence Product Use: An Integrative Review,” J Wound Ostomy Continence Nurs 2018 Jul/Aug; 45 (4): 341-348.

Continence Product Advisor, “Pads,” University of Southhampton, UK, 2019. Retrieved on September 30, 2019 from: https://www.continenceproductadvisor.org/products/pads.

Balk E, Adam GP, Kimmel, H, et al, “Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update. AHRQ Publication No. 18-EHCO16-EF. PCORI Publication No. 2018 – SR – 03. doi:  https://doi.org/10.23970/AHRQEPCCER212