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Treatment advances for millions with urinary problem

One out of every three women over 45 has an embarrassing problem when she sneezes, lifts a heavy bag or swings a golf club: She pees.

This loss of control, called stress urinary incontinence, leaves many of its 15 million victims -- most of whom are women -- feeling ashamed and frustrated. More than half the women questioned in a poll this fall were so uncomfortable about the leakages they hadn't even discussed them with their doctor.

And, until recently, women who did tell their doctors were told there was little medical science could do to help.

But now treatment ranging from simple exercises to surgery are showing that those who develop stress urinary incontinence aren't stuck with it forever.

"Incontinence is not a normal part of aging," said Dr. Stephen Young, chief of the division of urogynecology and reconstructive pelvic surgery at UMass Memorial Medical Center in Worcester.

The leakages, which are more common among women who have given birth, are caused by a weakening of the muscles and connective tissue that support the bladder and help close the urethral sphincter. Any physical activity that changes abdominal pressure can push the urethra down and open, causing a leak, Young said.

Strengthening the pelvic floor muscles through Kegel exercises is a good first step in treating stress incontinence, and sometimes the only one that's needed, said Dr. Patricia Goode of the Department of Veterans Affairs Medical Center in Birmingham, Ala.

Lifestyle modifications such as keeping fit, emptying the bladder regularly, and avoiding caffeine and foods or medicines with diuretic effects also may work for some people.

Seeking expert advice can also help. Urogynecologists like Young specialize in caring for women with pelvic floor problems. In a "urodynamics visit," the doctor may thread a very thin catheter with a microtip sensor through the urethra and record pressure in the bladder and sphincter. The process doesn't cause any pain, Young said, and helps tailor the treatment to the patient's diagnosis.

If noninvasive therapies fail, there are surgical options, too. Young's operation of choice for complicated forms of stress incontinence, the PuboVaginal Sling, holds up the urethra and bladder neck with a hammock and has a cure rate of 94 percent. A newer, minimally invasive operation called tension-free vaginal tape inserts a mesh under the urethra to hold it up, and 85 percent of those treated remain "cured" after five years, said Young, who has published several studies on incontinence surgery.

Other surgeries include stabilizing and elevating the urethra with permanent stitches or attaching it to the abdominal connective tissue (rectus fascia) via long needles. Collagen injections that bulk up the urethral sphincter can help women with very weak urethras, and for men who suffer from stress incontinence from prostate surgery, sometimes an artificial sphincter is created. These and other surgical treatments come with potential down sides of temporary urinary urgency, difficulty emptying the bladder, or erosion of the synthetic sling materials.

There are no pharmaceutical treatments yet for stress incontinence (the ones on the market help with urge incontinence, a different condition) but duloxetine has shown promise in preliminary studies. Duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, may improve nerve impulses that squeeze the sphincter shut. Pharmaceutical companies Eli Lilly and Co. and Boehringer Ingleheim are manufacturing the drug and expect FDA approval next year.

A Chinese herbal formula called BetterWOMAN, developed by Dr. Peipei Wu Wishnow, founder of the Marblehead-based company, Interceuticals Inc., claims to improve incontinence and urinary frequency, with the abstract of a small clinical study published in the November-December issue of Menopause journal.

Diane Newman, an advanced nurse practitioner and the codirector of the Penn Center for Continence and Pelvic Health at the University of Pennsylvania, said many of her patients have waited years to seek treatment. That shouldn't be the case, she said. "My hope is that women learn the symptoms of stress urinary incontinence, feel comfortable talking about it, and bring it up with their doctor, because this problem is treatable."

The National Association For Continence recently launched an online forum for discussion of incontinence at www.bladder-control-forum.com. Additional information is available through the American Urogynecologic Societyat www.AUGS.org and the Society of Gynecologic Surgeons at www.SGSonline.org.

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