Understanding Urinary Incontinence and Pelvic Floor Disorders
“Every day, I see women who have been living with urinary incontinence for years because they just thought it was part of being a woman, or part of getting older,” says Dr. Rebecca Nelken, a Los Angeles–based physician board-certified in obstetrics and gynecology and female pelvic medicine. “They think there’s nothing to be done about it.” Pelvic floor disorders, yes, are common. The idea that they’re something women just have to live with: untrue.
In some cases, pelvic floor problems will resolve on their own, Nelken says. But in others, women experience ongoing discomfort. Pelvic floor surgery, which one in eleven women will have in her lifetime, used to be the only option for urinary incontinence and pelvic organ prolapse, the two most common pelvic floor disorders. Now new, less-invasive options are being explored. “I want women to know what’s available so they can choose what’s right for them,” says Nelken. “If that means choosing not to have treatment, it shouldn’t be for lack of awareness.”
A Q&A with Rebecca Nelken, MD
Urgency incontinence is when women have a strong urge to go to the bathroom and urine leaks out before they get there. These tend to be women who go to the bathroom frequently throughout the day and even wake up to go at night.
Pelvic organ prolapse:
There’s an underlying genetic predisposition for pelvic organ prolapse, plus environmental factors including pregnancy and childbirth or anything else that puts pressure on the pelvic floor, like obesity, a chronic cough, sometimes even asthma. Risk peaks in the postpartum period, and then women may recover for some time on their own or with treatment. At menopause, with the loss of estrogen, there’s another peak in prolapse symptoms.
A lot of women feel uncomfortable physically, and that discomfort can severely limit their daily activities. An early sign is that women start avoiding workouts because that’s when their symptoms—typically either leaking urine or prolapse coming out during exercise—will be the worst. In a lot of cases, missing that activity long-term can lead to a drop in mood or other health problems. It sometimes even gets to the point where the discomfort interferes with basic activities, like walking around or going to work. A lot of women will wear pads for their leakage.
Often, if they feel that their anatomy has changed or if they have some urine odor, women might also feel uncomfortable being intimate with a partner.
For both stress incontinence and prolapse, Kegel exercises are a good place to start to rebuild the pelvic floor. In Europe, that preventive work is actually something that’s prescribed to mothers postpartum—and it’s paid for. Here in the US, it isn’t even covered by insurance.
For women who have healthy pelvic floors without pain and without tension, Kegels can also be a preventive measure for future incontinence and prolapse.
But note: For women who hold tension in their pelvic floor and tend to have painful intercourse or painful urination, Kegels could tighten the muscles further and make the pain worse. It’s important to have an exam with your gynecologist to see whether Kegels are right for you.
The gold standard of treatment for stress incontinence is surgery. We do a thirty-minute outpatient procedure where we place a sling under the urethra like a hammock to prevent stress incontinence.
There are also surgical solutions for pelvic organ prolapse.
A pessary is a plastic device that fits in the vagina and lifts up prolapse so women can go about pushing their stroller, feeding their baby, and living their daily lives while their body is healing. This way, they don’t have to be limited in their exercise—and often it’s only needed for a short time; a few months out they no longer need it.
Botox and nerve stimulation:
For urinary incontinence, there are a few options. We usually treat it with medication, or we can inject Botox into the bladder to stop unintended contractions. We can do a nerve stimulation procedure—it’s almost like using an acupuncture needle—in the office in six weekly sessions, or we can implant a nerve stimulator near the tailbone.
What I see so often is women who come to me complaining of recurrent urinary tract infections, and it’s not an infection at all—their cultures are actually negative. That’s a sign to me that there’s something else going on and you need to see a specialist to treat it instead of continuing to take antibiotics.
There’s a whole subset of patients I see who have pelvic floor pain and think they have recurrent urinary tract and bladder infections, but what they really have is interstitial cystitis—also called painful bladder syndrome—which isn’t a bacterial infection. Interstitial cystitis is a thinning of the bladder lining where you become much more sensitive to anything in the bladder. Those patients tend to have food associations with their sensitivities; spicy, acidic, and caffeinated foods tend to make their pain worse.
Nobody wants to take unnecessary medications or deal with their side effects—or contribute to antibiotic resistance. More significantly, when you have something that’s really bothering you and you’re not getting the right treatment, the problem isn’t getting fixed; you’re going to continue to feel bad until you get the correct diagnosis and treatment.
The vagina is skin, not dissimilar to the face, and we’ve adopted laser and radiofrequency technologies from the dermatology world. These treatments are designed to stimulate new collagen and tighten existing collagen. Collagen is the support structure of the connective tissue everywhere in our bodies—it’s what keeps the tissue strong. Our collagen, at a certain point, starts aging. After that, we may be able to naturally repair and replace it using interventions to stimulate new collagen, which may be helpful in treating mild prolapse and mild forms of urinary incontinence.
These treatments can also increase blood flow to ameliorate vaginal dryness without the use of hormones. For vaginal dryness following menopause or childbirth, when endogenous estrogen is low, the gold standard treatment is estrogen—but a lot of women can’t use estrogen or are uncomfortable doing so.
I have seen an overwhelmingly positive response with radiofrequency. I think that because it’s not a surgical procedure, there are a lot of upsides without significant downsides.
Patients might have a lot of symptoms that bother them, but they might be like: Okay, my vagina’s not as tight as it used to be, and it’s annoying—but I’m not going to go under the knife for it. Surgery used to be the only option, and that’s extreme. But now that there’s something we can do in the office with minimal risk and no downtime, that’s a game changer. Women are going for it and getting results, and I’ve heard from so many patients who are overwhelmingly happy.
There are always risks, but they’re minimal. If you’re talking about the risk of a burn, which heals and is rare in the first place, it’s a nearly negligible risk. It’s an individual choice: If you’re talking about, say, a breast cancer patient who’s menopausal in her thirties or forties and doesn’t feel comfortable having sex because her vagina’s so dry and it’s uncomfortable, and because of her breast cancer she can’t use hormones, well, I think that patient might happily take that minimal risk.
In this age of women’s empowerment, this is a conversation we need to be having. It’s not a sexy subject, but it doesn’t need to be taboo—and women can support one another by sharing their own journeys. As options for supporting pelvic floor health are becoming more accessible, women are getting more comfortable talking about it.
As treatment is becoming more accessible, women are getting more comfortable talking about it. There are a lot of companies creating nonsurgical and noninvasive ways to treat vaginal dryness and urinary incontinence with radiofrequency and laser treatments in the doctor’s office, and now there are even at-home LED devices that women can use on their own.
For a lot of postpartum women, urinary incontinence and prolapse will resolve on its own—but I want women to be aware there are treatments to help in the short-term.
Rebecca Nelken, MD, is a Los Angeles–based physician who is board-certified in female pelvic medicine and obstetrics and gynecology. Nelken has a BA from Columbia University and completed her MD, medical internship, residency in obstetrics and gynecology, and residency in female pelvic medicine and reconstructive surgery at the University of Southern California. She is also an assistant professor of clinical obstetrics and gynecology at the Keck School of Medicine at USC. Her goal is to empower women by educating them about their bodies and to combat taboos around women’s pelvic health.
This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.