Over the years, Kathy Duffy, a 38-year-old school teacher in Reading, tried many treatments for her severe incontinence — pills, injections, exercises, even “retraining” her bladder.
Everything helped some. Even so, she was always ducking out on her second graders to rush to the bathroom. She didn’t sleep much, either. The urge to urinate woke her every hour or so.
Two weeks ago, Duffy and two other women became the first patients in New England to have a new electrical device called InterStim implanted near their spines to calm bladder spasms.
For the first time in years, Duffy says, she’s sleeping five hours at a stretch, thanks to the device, which seems to slow the excessive firing of nerves to the bladder.
Urinary incontinence strikes 15 million Americans, most of them women and most, like Duffy, well under 65. Unlike Duffy, many of those whose bladders betray them suffer in shameful silence, avoiding other people lest they have an “accident.”
Luckily, researchers and venture capitalists are not so shy. In fact, convinced of the demand for something better than adult diapers, they’re racing to develop pills, plugs, and other devices to keep bladders from their dismal dripping.
Incontinence comes in two main forms — urge problems like Duffy’s, in which bladder muscles go into spasm, making it impossible to stop urine flow once it starts; and stress problems, in which weak sphincter or pelvic muscles fail to keep the bladder neck closed during sudden physical stresses like coughing, sneezing, laughing, or exercising.
It can also occur when an obstruction — usually an enlarged prostate in men — blocks urine flow, leading to overflow or urge problems.
“For every kind of incontinence, there’s a pill, or behavioral intervention, a device or an operation,” says Dr. Neil Resnick, an incontinence specialist at Brigham and Women’s Hospital. “Cure is usually possible, and usually without surgery.”
The trick is to diagnose what kind of incontinence you have — you can have more than one — and be savvy about your options.
In the past, for instance, incontinent women were often told to have a hysterectomy. But you don’t need that, says Dr. Deborah Lightner, a Mayo Clinic urologist, unless your uterus has prolapsed and is pressing on the bladder.
In fact, for most people the best bet is to start with the simplest, least invasive options.
For stress incontinence, this means Kegel exercises, in which you strengthen pelvic floor muscles, which can be damaged by giving birth. To identify these muscles, try stopping urine flow in midstream. If you can, you’ve got the right muscles. Once you’ve found them, make that same exertion 100 times a day, but not during voiding lest you retain urine.
If you can’t pinpoint those muscles on your own, go to a continence center (many hospitals have them) and ask for biofeedback training, a system of electrical sensors on patches on the skin or in the vagina or rectum that send an unmistakeable signal when you contract the right muscles.
If your problem is urge incontinence, bladder retraining can help. You try to stick to a pre-set bathroom schedule, urinating regularly before the bladder gets too full, and learning to suppress temporarily the urge to urinate.
If these simple behavioral tricks don’t help, there’s a slew of devices to control leaky bladders, most of them available by prescription. Some women, for instance, use vaginal cones, tampon-like devices held in the vagina for 15 minutes twice a day to strengthen pelvic muscles.
Others use pessaries, like Introl, that are inserted into the vagina to support the bladder neck, though these have to be carefully fitted and changed regularly. Other women prefer a product like Capsure that plugs the opening of the urethra; it stays in place by suction and is pulled out by a nipple during urination. New devices like Inflow, which is not yet approved, may be left in the urethra for as long as a month.
Soon, women may also have another option — a foam patch called Impress that’s designed to stick to the urethral opening like a tiny BandAid. Impress has been approved but has not yet been marketed for over-the-counter use.
If none of these options works, you can try collagen injections — done via a needle passed through the urethra. The collagen squeezes the side of the urethra together, slowing urine flow.
For sheer convenience, many women opt for medications rather than devices. Estrogen, for instance, can make the urethra more pliable and easier to seal and it can be taken in a variety of ways — pills, patches, vaginal cream or a vaginal ring that releases the hormone slowly.
For urge incontinence specifically, other drugs also help — including old standbys like Ditropan and newer ones like Levbid and Detrol, says Dr. David Staskin, director of the continence center at Beth Israel Deaconess Medical Center.
These drugs all block acetylcholine, a chemical secreted by nerves that tells muscles to contract. The newer verions of this medication cause fewer side effects such as dry mouth and constipation.
Tofranil, an anti-depressant that has the useful side effect of relaxing bladder spasms and tightening the sphincter, can also help, says Dr. Stanley Swierzewski, III, co-director of the Lahey Clinic continence center.
For men with incontinence caused by an enlarged prostate, drugs like Minipress, Hytrin, Cardura or Flomax that relax the urethra can be very helpful. So does shrinking the prostate itself — with a drug called Proscar, microwave therapy, or surgery.
Surgery is also an option for some women, and for those with stress incontinence two options work well. In the “suspension” procedure — done through a vaginal or abdominal incision — surgeons stitch a drooping bladder to ligaments in the pelvis. In the other, a “sling” is made for the bladder with fascia tissue from the patient or a cadaver.
In the past, surgery has not been a useful option for women with urge incontinence. But surgery to implant the InterStim “pacemaker” like Duffy should become a growing option.
The theory behind InterStim is that urge incontinence is triggered by overactive nerves called C-fibers that run from the spinal cord to the bladder. The C-fibers are believed to govern urination in babies, whose bladders empty uncontrollably. These fibers are thought to be quiescent in adults, though they can be reactivated, sometimes after back surgery or pelvic trauma.
Applying an electric current to the bladder nerves seems to shut down the C-fibers but not normal fibers, says Swierzewski, who implanted the device in Duffy and two other patients.
Other researchers are cautious. InterStim has been tried in fewer than 200 patients at about half a dozen centers, says Resnick. “The results are promising, but the number of people who’ve had the device implanted is still small.”
But Duffy needs no convincing: “I’m very pleased.”