Chapter 82
Healing with Side Effects
In women with obesity, the risk of severe incontinence is three times higher than in women with a healthy weight. That may be because greater pressure builds up on the bladder in the abdominal cavity. Beyond observational data, intervention studies show that even a small weight loss can help. The PRIDE program to reduce incontinence through diet and exercise, for example, organized a weight-loss program in a randomized study with hundreds of overweight and obese women; there was also a control group that received only general information on health topics at events. Participants in the weight-loss group lost a total of about 14 pounds more than the control group and also recorded significantly fewer incontinence accidents. After six months, the frequency of incontinence accidents had been reduced by more than half in 61 percent of women in the weight-loss group; in the control group, it was only 34 percent.
With or without incontinence, an overactive bladder is defined as urinary urgency, and you often have to go to the toilet more frequently. More than one in three women suffers from an overactive bladder at some point in her life, and the older she is, the more likely it becomes. However, a randomized, placebo-controlled double-blind study found that salvation may be only half a gram of dried cranberry powder away. Symptom control with bladder-relaxing medications like tolterodine (marketed as Detrusitol) is a multibillion-dollar business, but on average they reduce urination by 16 times a month—that’s about one less pee every other day. A quarter teaspoon of cranberry powder, however, worked almost four times better and led to about two fewer trips to the bathroom a day. And without the medication’s side effects such as dry mouth, constipation, drowsiness, reduced cognitive function, heart palpitations, incomplete bladder emptying, and visual disturbances, which prompt nearly two thirds of patients to stop taking the drug.
The tabloid press advises those affected to avoid “irritants for the bladder,” meaning spicy, salty, and sour foods. This recommendation is not supported by any published evidence, but the nice thing about harmless and simple dietary changes is that it doesn’t hurt to try them out and see whether you feel better afterward. The only two dietary components for which a long-term study with more than 5000 women found an association with stress incontinence were saturated fat and cholesterol, although these may simply be markers of an unhealthy diet or an unhealthy lifestyle. There appears to be no association between intake of phytoestrogens (e.g., soy and flaxseed) and urinary tract symptoms. Should you cut back on coffee consumption?
Guidelines in the USA and in Europe recommend reducing caffeine intake. That makes sense, too. Caffeine is mildly diuretic, especially in the amount of two or three cups of coffee, even if habitual coffee drinkers have probably adapted to this effect. However, surprisingly, a meta-analysis of observational studies found no association between urinary incontinence and coffee consumption or caffeine in general. Two of four intervention studies on caffeine reduction found a decreased number of trips to the bathroom (the other two observed no significant effect), but only two of seven such studies that tracked incontinence episodes found a decisive improvement. But as I said, trying it doesn’t hurt.
Reducing fluid intake in general could be counterproductive, because more concentrated urine can irritate the bladder lining and paradoxically worsen the feeling of having to go often and urgently. Even so, I would recommend avoiding diet drinks. A head-to-head comparison showed that diet cola made people run to the bathroom more often than regular cola. The researchers attributed this to the artificial sweeteners, which in in vitro studies on rat bladders triggered increased muscle contraction.
Healing with Side Effects
Medications that prevent the bladder muscle from contracting can be prescribed for urge incontinence. The cure rate is about 50 percent, but they have the side effects I mentioned above. That may explain why only 14 to 35 percent of those prescribed these medications are still taking them a year later. There are no FDA-approved medications for urge incontinence, but surgical procedures have a cure rate of more than 80 percent.
Surprisingly, there is plenty of evidence that systemic (oral) estrogen therapy actually worsens incontinence. For example, in the Women’s Health Initiative, continent women who received estrogen became stress-incontinent in the first year nearly twice as often as women in a placebo group. However, locally (vaginally) applied estrogens appear to help, preventing about one or two accidents a day. Still, the best measure against urinary incontinence is neither pharmaceutical nor surgical. Five times better than locally applied estrogen in a direct comparison was: pelvic floor training (Kegel exercises).
In 1948, Dr. Arnold H. Kegel published a paper in which he described a successful therapy for urinary incontinence that strengthened the muscles between the pubic bone in front and the tailbone in back. You can tell which muscles are the right ones when you stop the flow midstream. The Mayo Clinic recommends imagining that you are sitting on a marble and trying to lift it with the vaginal muscles. You should hold the contraction for ten seconds, then relax for at least ten seconds, and do this 30 to 100 times a day for at least one month if you want to see initial results. What helps motivate you to stick with it is that trained pelvic muscles are rewarded with better orgasms and greater sexual satisfaction.
Once your pelvic floor muscles are trained, you can squeeze them when you suddenly have to go or you feel that you’re about to sneeze. With urge incontinence, you can combine this with bladder training, in which you start by urinating hourly during waking hours and increase this interval each week by a half hour at a time until you manage to let two and a half to three hours pass between bathroom trips. A meta-analysis of 31 studies involving more than 1800 women with urinary incontinence from 14 countries found that those randomized to train their pelvic muscles were, on average, five times more likely to be cured (with stress incontinence, eight times more likely).
Somewhat Stretched
Physical activity is associated with a lower risk of urinary incontinence, but the only intervention studies on exercise not focused solely on the pelvic floor are yoga studies. See see.nf/yogatrials for details, but overall the takeaway is: In a control group that was given just as much time and attention, the subjects did nonspecific exercises to stretch and strengthen the muscles. In comparison, those who actually practiced yoga showed a clear improvement in stress incontinence, but not in urge incontinence.
Enlarged Prostate
When older men have trouble urinating, in most cases it is related to an enlarged prostate gland, also known as benign prostatic hyperplasia (BPH). It affects millions of men in the USA—half of 50- to 60-year-olds and about 80 percent of 80- to 90-year-olds—and thus BPH is among the most widespread diseases in men in Western populations. The prostate surrounds the bladder outlet and can therefore impede normal urine flow if it becomes too large. This restriction can weaken the urinary stream, interrupt it repeatedly, and prevent the bladder from emptying completely, so you have to use the toilet often. In addition, residual urine in the bladder can become a breeding ground for infections.
Drug and Surgical Treatment
Unfortunately, the problem gets worse as the prostate continues to grow. Millions of Americans have undergone a procedure, and billions are spent on medications and dietary supplements. Currently used drugs like finasteride (Proscar) are clinically effective, but their effectiveness is undermined by the fact that they have side effects and those affected do not accept them. Side effects include sexual dysfunction, high-grade prostate cancer, and depression. No wonder men don’t like taking it! A study of more than a million Americans found that only 29 percent took the drug for even a year.
Forms of sexual dysfunction that occur with finasteride include impotence, reduced libido, ejaculatory disorders, and gynecomastia (growth of the male breast). In 2021, legal action by the news agency Reuters led to the publication of internal documents from Merck, the manufacturer of Proscar. As it turned out, Merck had already known in 2009 that this medication causes persistent erectile dysfunction (even after it is discontinued), but Merck’s “risk management safety team” had decided to make that information disappear into a drawer.