Treat incontinence without drugs or surgery.

My cousin's child, at about age 4, didn't make it to the bathroom in time, and burst into tears of embarrassment be-cause she had piddled on the floor. "It's just an accident, nothing to worry about," I said, soothingly, "You know, even grown-ups have accidents." She was so astonished that she stopped crying, mid-sob.

Adults don't talk about it much, but incontinence is common, especially among women. There are two sorts of urinary incontinence. "Stress incontinence", the loss of urine during coughing, laughing, sneezing, or exercise: "urge incontinence" is a sudden urge to urinate immediately followed by involuntary urine loss.

The most effective, safest, and cost-effective therapies for treating urinary incontinence are pelvic floor muscle (PFM) exercises and a kind of behavioral therapy called "bladder retraining." PFM exercises are what my generation called Kegel exercises. Named for U.S. physician A.H. Kegel, the exercises involve strengthening the muscles located in and near the vagina that keep us continent. While Kegeling was promoted to my generation as a sex improvement technique, it may be even more important for preventing and treating incontinence.

To do PFM (or Kegel) exercises, tighten the vaginal muscles as though you were stopping urine flow, and then tighten the muscles of the anus as though you were trying to stop a bowel movement. For both exercises, pull upwards and inwards, hold for a count of three, then relax. Do a set of 5-10 several times daily and try to work up to holding the positions for 10 seconds. Alternate sets of long slow contractions with sets of fast flicks. Try not to involve the abdomenal or buttock muscles.

If you have trouble identifying the muscles to tighten, insert 1-2 fingers into your vagina and try to squeeze your fingers with your vaginal muscles. Or, try to stop your urine flow midstream (don't do this on a regular basis, as it creates turbulence in the bladder, which is bad for you--but it's okay to do it while learning the technique). PFM exercises can be done anywhere: while watching TV, commuting, or in meetings, in elevators--the possibilities are endless.

Some people find PFM exercises difficult to learn, leading to the invention of vaginal weightlifting aids. Vaginal cones, which are sold through catalogs, are weighted, plastic, tampon-like devices that are placed into the vagina, and fall out if the pelvic muscles are inadequately contracted. The weights are graduated so that, after successfully learning to hold in lighter weights, a woman moves on to heavier ones. If these measures don't work, biofeedback preferably with bladder retraining should be the next step. The biofeedback technique teaches people how to control their muscle tone (or other bodily processes) by using audio or visual signals. For incontinence, one tries to contract the PFM muscles while relaxing the abdominal muscles (which may seem impossible to do simultaneously at first). Several techniques can be used, including one where a small device placed into the vagina translates information about muscle tone through beeps or visual images. By learning to control these signals, women can learn which muscles to contract. The machines are unnecessary once the technique is mastered.

Behavioral training sessions help people learn alternatives to bolting desperately for the bathroom when they experience the urge to urinate. Behavioral training involves learning "urge strategies", which involve sitting down, relaxing, contracting their pelvic muscles repeatedly, then proceeding to the toilet at a normal pace once the feeling of urgency subsides.

Many randomized controlled trials have demonstrated the effectiveness of these therapies in diverse populations, including homebound elders, women who have just given birth, and female soldiers with exercise-induced incontinence.

Physicians often prescribe drugs (like oxybutynin and tolterodine) but biofeedback-assisted behavioral therapy is just as effective. Incontinence drugs relax muscle cells in the urinary tract, but also slow motility in the gut, so constipation can be a problem. Other side effects include dry mouth and eyes, headaches, abnormal vision, and urinary retention. Various surgeries have also become popular: while it can be effective, surgery should be a last resort. For urinary incontinence, biofeedback and behavioral therapies should always be tried first.

Your doctor may not know about PFM exercises and biofeedback, but now you do. Tell your friends! For more information or a referral to a biofeedback therapist in your area, contact:

Biofeedback Certification Institute of America: 10200 West 44th Ave, #310, Wheat Ridge, CO 80033 303.420.2902 Website: www.bcia.org

Association for Applied Psychophysiology and Biofeedback: 10200 West 44th Ave, #304, Wheat Ridge, CO 80033 3o3.422.8436 Website: www.aapb.org

Adriane Fugh-Berman, M.D., is an associate professor in the department of physiology, Georgetown University School of Medicine, and a former chair of the NWHN.

References for this article are available from the editor; email [e-mail]