I am 33. I have two daughters, ages 2 and 7, both born by cesarean. I have always had a weak bladder, but it seems with each childbirth it became weaker and weaker. After my hysterectomy four months ago it has become a major problem. I have no control whatsoever. By the time I feel the urge, it's too late. Could this be related to a procedure I had when I was two years old to stretch the opening of my urethra? Will some of the strength come back with time? I am way too young to live the rest of my life in Depends!

Wendy

Urinary incontinence is a problem that plagues millions of women, young and old. Pregnancy itself, even without a vaginal delivery, is a risk factor, especially if there was any laboring at all. Obesity, smoking and plain old bad genes are other risk factors.

Incontinence can be due to mechanical problems such as dropping of the bladder. This "stress incontinence" is the type most commonly blamed on childbirth. In such a case, the woman typically finds she urinates unexpectedly when she coughs, sneezes, laughs, or engages in exercise or other activity. The main methods of treatment for this are Kegel exercises, a pessary (a device inserted into the vagina) or surgery.

Incontinence may also result from spasms of the bladder muscle; this is called detrusor instability or just "overactive bladder." Past surgery, such as a hysterectomy, may damage some of the nerves to the bladder, leading to uncontrollable and unpredictable spasms. This is accentuated when the bladder is full. Many women with this type of incontinence describe leakage when they get the urge to go -- if a bathroom is not right there, they leak. Medication to relax the bladder muscle and diminish the spasms is the mainstay of therapy for this.

The least common type of incontinence, overflow incontinence, happens when the bladder fills to a certain point. It's like pouring water into a glass: When the capacity of the glass is reached, any additional water will overflow onto the table. Women with this type of incontinence will leak out of the blue, while sitting still and without any sensation of needing to empty their bladders. This type may be associated with neuromuscular conditions such as multiple sclerosis, or it may reflect a defect in the urethral sphincter, the muscular band that controls the opening through which urine flows. If the sphincter does not function properly, the urethra will not remain closed, and urine will leak out without any warning. Emptying the bladder at regular intervals or surgical techniques to improve the urethral sphincter are the most common treatments.

Proper treatment of urinary incontinence depends on proper diagnosis. Your gynecologist is a good starting point, but sometimes referral to a urologist is necessary. For difficult cases, often the best doctor to seek out is a urogynecologist, a specialist in female urinary problems. A thorough history and physical exam coupled with testing of bladder function (urodynamic testing) will usually provide the correct diagnosis.