Opinion | Let’s Break the Incontinence Taboo

I hope that someday soon I wake up to one of those oft-mocked headlines that reads:

“Millennials killed the incontinence pad industry.”

If that day comes, it means that we have finally done our job as urogynecologists to dismantle one of the most pervasive and infantilizing myths that exists: that urinary leakage is an inevitable and acceptable part of the lived female experience.

A study published in 2021 from the Urologic Diseases of America Project found that half of American women experience urinary incontinence — so the problem is far from rare. But just because it is common, it doesn’t mean that it is normal, and certainly doesn’t mean that it is unfixable. How bad does it have to be before women decide they deserve to live a full, pad-free life?

Women are expected to become mothers, but punished when they do.

We still live in a world where, from a young age, girls receive the message that to truly arrive in society, they are destined for motherhood, regardless of their other hopes and dreams. But as sure as that happens, they accept that the price of childbirth is they might pee themselves a little bit if they exercise, laugh, or sneeze (stress incontinence) or as they age, they might not be able to make it to the bathroom in time (urge incontinence). “That’s just what happens when you have a baby! It’s part of being a woman! Keep a pad and clean underwear in your purse just in case.” Women are told this by their mothers and their grandmothers who have experienced the same. Men, of course, don’t even know this is happening, because nobody ever talks about it.

Incontinence keeps women from fully actualizing what they are capable of.

But how many of this quarter of our population are shrinking from their life, making themselves smaller, as they spend precious energy navigating their existence around the fear of having an accident? How many aren’t fully moving their bodies in the way they want to, are sitting out the dance floor at weddings, or feeling like an imposter at work because they’re leaking when they should be leading? How many are skipping church, avoiding friends, and passing up opportunities so they can stay home by the safety of the bathroom? All told, an enormous sacrifice is born out of fear of a condition that is wholly treatable. The lie that incontinence can’t be fixed has been one of the most successful campaigns ever launched to hold women back from reaching their full potential.

When you imagine an incontinent woman, who do you see?

The mental image most of us have of an incontinent woman is a feeble “old” grandmotherly person (and note that when I say “old,” people tend to associate that with “menopausal” — a stunningly mismatched impression when you consider that perimenopause starts at 40 and the average age of menopause in the U.S. is 51). For reference, our 57-year-old formidable Vice President, Kamala Harris, is likely a “menopausal” woman. This stereotype falls apart further with the realization that millennial women are now 30 to 40 years old. Thanks to widespread access to health information via social media channels, my ardent prayer as a urogynecologist is that incontinence isn’t a biologic inevitability they are going to take sitting down.

We need to stop the madness.

So, what can be done about incontinence? In the briefest terms, it depends on what type patients have. Stress incontinence is leakage with exercise, lifting, laughing, or sneezing, caused by a “weak” urethra that loses its support from childbirth, constipation, or obesity. Urge incontinence is leakage when a person has to urinate so badly that they can’t hold it — this is due to uncontrolled bladder spasms. Many women have mixed incontinence, which is a combination of both. Both stress and urge incontinence can be treated with pelvic floor physical therapy (bladder retraining). In addition, stress incontinence can be treated with an incontinence pessary or more definitively with urethral bulking (fillers) or an operation called a midurethral sling, which is actually the longest and best-studied implant in any type of surgery. It is minimally invasive, has a short operative time, and is very effective when done by a trained high-volume surgeon. Urge incontinence can be treated with medications or botox injections (to control bladder spasms). If those don’t work, the nerves to the bladder can be controlled with a “bladder pacemaker” called sacral neuromodulation. Mixed incontinence can be treated with a combination of these things.

If a pad falls in the woods, does anybody hear it?

Despite all of this great science and innovation, none of it helps if women don’t feel empowered enough to ask their doctors about treatments because they don’t know they exist. Like most diseases, early diagnosis and management leads to better outcomes than waiting until the situation is dire — so it is worthwhile to bring it up with patients who could be experiencing incontinence and encourage them to see a specialist like a urogynecologist as soon as possible. Aside from better medical outcomes, taking action early can prevent patients from arranging their lives around fear and embarrassment, which can lead them to be less than what they’re meant to be.

Let’s talk about it early and often.

So how do we change this? Like most things, we can make a change by talking about it, unashamedly, on the internet and to each other in an intergenerational fashion. By making the truth about childbearing outcomes and female aging commonplace without normalizing it. By raising girls to speak up when they are uncomfortable or are being held back by a lack of control over their bodily functions. By training diverse physicians. By including men in the conversation.

So, if you or your patient leaks urine, tell them that treatment isn’t just good for their health, it’s good for all of us — the world needs everything women have to offer (and fewer pads).

Jocelyn J. Fitzgerald, MD, is an assistant professor of obstetrics, gynecology, and reproductive sciences in the Division of Urogynecology and Reconstructive Pelvic Surgery at the University of Pittsburgh School of Medicine.