Bladder leaks and the pelvic floor after 40

Key takeaways

• There are two main types: stress leaks (with coughing, sneezing, lifting) and urge leaks (a sudden strong need to go). Many women have both.
• NICE recommends at least three months of supervised pelvic floor training as the first treatment for stress and mixed leaks.
• In a Cochrane review, women with stress leaks who did pelvic floor training were about eight times as likely to be cured as those who did not.
• Bladder training for at least six weeks is first-line for urgency.
• Reducing tea and coffee, managing weight, and treating constipation and cough all reduce leaks.

Why do leaks start in midlife?

Women whisper this to me at the very end of a consultation, almost as an afterthought. "Doctor, one more small thing..." And it is never small, because it decides whether she goes for a walk, sits through a wedding, or laughs freely with her friends.

Picture your pelvic floor as a hammock of muscles slung across the bottom of your pelvis. It holds up the bladder, womb and bowel, and helps keep the urine tube closed. Over the years, many things stretch that hammock:

• Vaginal births, especially large babies or long labours
• Weight gain, particularly around the middle, which presses down on the bladder
• Chronic cough from allergies, asthma or smoking, common during Mumbai's monsoon and winter pollution
• Constipation and straining
• Heavy lifting, such as carrying water buckets, gas cylinders or grandchildren
• Lower estrogen around menopause, which thins the tissue around the urine tube and bladder
• Diabetes, which can affect bladder nerves and increase urine output

The NHS is clear that incontinence is not an inevitable part of ageing. The point is, most of these causes can be worked on.

Which type of leak do I have?

One simple thing I ask for: a bladder diary for three days. Note what you drink, when you pass urine, and when you leak. Bring it with you. It literally tells me half the story before I examine you.

How do I do pelvic floor exercises correctly?

Almost every woman has heard of "Kegels". Very few do them correctly, and most give up after two weeks. NHS guidance from the Lancashire and South Cumbria pelvic floor physiotherapy service explains the technique, and this is how I teach it:

Find the muscles. Imagine stopping yourself passing wind and passing urine at the same time. You should feel a squeeze and a lift inside. Don't hold your breath, don't squeeze your buttocks, don't press your thighs together.

Slow holds. Breathe out as you squeeze and lift. Hold for up to 10 seconds, then fully relax for 5 to 10 seconds. Repeat up to 10 times.

Fast squeezes. Squeeze and lift quickly, then let go straight away. Repeat up to 10 times.

How often. NICE recommends programmes of at least eight contractions, three times a day. Quality matters more than number. One focused set is better than three rushed ones.

The knack. Tighten your pelvic floor just before you cough, sneeze, lift or stand up. Over time this becomes automatic, like checking your mirror before you change lanes.

Be patient. It can take up to three months to notice improvement. Tie your sets to something you already do daily: morning tea, the train ride, the evening serial.

If you are not sure you are squeezing the right muscles, ask for an examination. A trained physiotherapist or doctor can check your technique. NICE specifically recommends that training be supervised, because doing it wrongly for three months is three months lost.

What else helps?

Bladder training for urgency. NICE recommends at least six weeks of bladder training for urge or mixed leaks. When the urge comes, stop, squeeze your pelvic floor, breathe, and wait a few minutes before walking calmly to the toilet. Slowly stretch the gap between visits. You are teaching the bladder that it is not in charge.

Fluids. Please don't cut water drastically. Concentrated urine irritates the bladder and can lead to infections. Aim for pale yellow urine, and drink less in the two hours before bed if you wake at night.

Caffeine. NICE suggests a trial of reducing caffeine for overactive bladder. Three or four cups of strong chai or filter coffee a day add up. Try decaf or herbal options after lunch.

Weight. NICE advises weight loss for women with a BMI over 30. Even modest loss takes pressure off the bladder.

Constipation. More fibre (whole dals, vegetables, fruit, isabgol if your doctor agrees), water and daily movement. A small footstool under your feet on a Western toilet helps you empty without straining.

Cough. Get a persistent cough treated and stop smoking.

Local estrogen. Where leaks come with dryness or burning after menopause, low-dose vaginal estrogen may help the tissues. NICE also suggests considering it before fitting a support pessary. It is a prescription decision made after assessment. See dryness and discomfort after menopause.

What if exercises are not enough?

If three months of well-done pelvic floor training has not helped enough, there are further options we can discuss:

• Medicines for overactive bladder, when bladder training alone is not enough
• A vaginal pessary (a soft support device) for prolapse, which NICE says should be removed or changed at least every six months
• Referral to a urogynaecologist for tests and, in some cases, surgery

Some signs need prompt assessment, not waiting: blood in the urine, pain, repeated urine infections (see repeated urine infections after menopause), difficulty passing urine, or leaking of stool. NICE lists these among reasons for specialist referral.

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha in Thane West, bladder control is part of the long consultation in The Right Stop Programme. You talk to a woman doctor in a private room, and nothing is too embarrassing to mention. I can check your pelvic floor technique, look for related causes such as dryness, prolapse or blood sugar, and refer you onward when a specialist is needed.

Written by

Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187

Leads midlife women's health at Cocoon × Dr Tvacha, Thane.