There are nappies in my wardrobe, but I have no children nor a sexual fetish. Instead, I have a problem shared by millions of women (and some men): I cannot always control my bladder as well as I want to, no matter how many toilet visits I have made beforehand. I have incontinence, and I am not alone: in the UK, up to 40 per cent of women have incontinence at some point, either because they have given birth or are menopausal, because of genetics, or simply because of age. Up to 70 per cent of expectant and new mothers experience incontinence, and a quarter of men over 40. Given how shameful it is thought to be, these figures are likely to be conservative. We mask, we hide, we cope.
The pelvic floor – a sling of muscles stretching from the tailbone to the pubic bone – supports the bladder, bowel and womb. These muscles are meant to contract to stopper any flow of urine. (The muscles are also sometimes referred to as a “trampoline” – a sour joke for women who know trampolining is a sure way to wet pants.)
Incontinence can be caused by childbirth, long-term cough, constipation, being overweight, pelvic surgery, repeated heavy lifting or menopause. There are several varieties: urge incontinence, when your urge to urinate is so sudden you can’t control it; overflow incontinence, when you have trouble emptying your bladder fully and leak; and total incontinence, when your bladder cannot hold urine. Functional incontinence, where other conditions prevent you getting to a toilet in time, is one reason. Another is ageing muscles, which makes incontinence common among the elderly: after the age of 70, 17 per cent of women and 12 per cent of men have some incontinence. Mine is stress incontinence, which can be triggered by laughing, coughing, sneezing or jumping, because my pelvic floor can’t prevent my bladder from emptying under the pressure.
My bladder problems arrived with the menopause, which is normal: nearly half of women report trouble with continence after their last period, either because the lack of oestrogen thins the lining of the urethra, or because of muscle weakness. I am not ashamed of being menopausal, so why am I ashamed of my pelvic floor weakness? But I never admitted to the nappies, sold as “incontinence pants” and posted in anonymous envelopes. For months on end, they were my salvation because they weren’t bulky or obvious, and they meant I could run for hours and not smell like a toilet afterwards.
Magic knickers
I have now found better options in the form of modern and more stylish incontinence knickers that absorb urine, made by companies such as the Manchester-based Giggle Knickers. Co-founder Anne Davidson says she wanted to create incontinence pants that looked like "a comfortable pair of knickers" – a product that makes it easier to break the stigma around the condition.
“We think it’s a basic thing you should be able to do,” says Davidson. “[Incontinence] is associated with being a baby, or being old – like you’ve lost it a bit.”
If you look at the figures, incontinence is an epidemic: 14 million people have bladder problems in the UK. The last recorded estimate, from 2000, of how much incontinence costs the NHS for women living outside care settings was £233 million, with another £178 million for self-care (such as my "magic pants" and nappies). Though it is less common than in women, men get incontinent, too – often later in life, as a result of prostate troubles. Davidson says men have written to her asking her to make a product for them, because they are cutting up their wives' sanitary pads and using those. Often they suffer in silence. And it is suffering: sanitation specialists talk of the "bladder leash", when people stay at home because they dare not go out in case they don't find a public toilet. Urinary incontinence is embarrassing, diminishing and disabling.
Many women only approach their doctors for help when they have reached a point of desperation, or need surgery. The Nice guidelines on incontinence are clear: the first step for anyone suitable is exercises. You know the ones – the squeezes and the pulses you do, though you are never sure if you are doing them right. They don’t work for everyone: women who have had surgery that has cut through nerves and tissue, or women with neurological issues or medical conditions can do all the pelvic floor exercises they like, but they will still leak. But in cases of stress incontinence, strengthening the pelvic floor can improve life for 70 per cent of sufferers.
A few years ago, I was referred to an incontinence clinic, where a kind nurse took a look and told me I was fixable, but that I had to do the exercises. I said I would and didn't. Who does? Studies show up to half of women either don't do their exercises correctly (the pelvic muscles are hard to isolate) or stop doing them. I was given a Kegel device, named after the Chicago gynaecologist Arnold Kegel, who invented the squeezes. This pulsed electricity at my pelvic floor "trampoline". If I used it regularly for many weeks, there was a slight improvement, but I lapsed. It was boring and I was unsure whether it was working.
Then I was sent an Elvie trainer. The Elvie is sea-green and curved, and it looks like it could be an alien gadget in Guardians of the Galaxy. It’s straightforward to use: you insert it like a tampon for your short exercise session, the “tail” connects with a smartphone app via Bluetooth, and off you go. There are other apps aimed at encouraging Kegel exercises, such as Squeezy. But Elvie combines several elements: biofeedback, so that it can sense whether you are squeezing correctly; alerts if you are doing them wrong; and gamification, a tech term meaning that users are lured by targets and competition.
Pelvic floor
Elvie's founder is Tania Boler, a former specialist in sexual health, HIV and reproduction who has worked for the UN. Her incontinence was triggered in 2011 by giving birth, which can stress the pelvic floor because of the pressure of a growing foetus and a uterus expanding to accommodate it, or because of birth trauma. "I suddenly realised I didn't know anything about my pelvic floor," says Boler.
She read the literature and found women’s health to be vastly under-researched. Surely, Boler thought, it was time for a product that made pelvic floor exercises easier? But this was years ago, before vaginal steaming became a celebrity trend. She was trying to sell what is now called “femtech” to an overwhelmingly male tech industry and was, predictably, scorned.
In 2013 Boler entered an innovation competition run by the UK government and won £100,000. She handed in her notice the next day, convinced Alex Asseily, the founder of the electronics company Jawbone, to invest (he became a co-founder of her company a year later). She wanted a device that had a sound medical foundation but was fun to use – so she looked to gaming for what she needed. The games industry term is "sticky", meaning people come back because of the targets and rewards. With Elvie, the competition is with yourself, but is still compelling.
One of Elvie’s core customer bases is young women – who think the menopause is decades away. “Women in their 20s,” says Boler, “who are not thinking about motherhood, but want to strengthen their pelvic floor either because they are very into exercise, or because they are more conscious about being healthy.” There are also more immediate benefits. “Obviously a stronger pelvic floor means better sex. People say: ‘Is it a sex issue or a health issue?’ But it’s both. If women are doing it for sex and it has knock-on health benefits, that’s even better.”
If incontinence was less unspeakable, women would not end up needing surgery that can be distressing and sometimes – as class action suits over vaginal mesh implants show – harmful. “It’s just switching what we think of typically as a negative health issue,” says Boler, “something that we’re embarrassed about and don’t want to think about, and turning it into something positive.”
I love my Elvie and my magic pants, and will continue to use both for as long as I need. Is it fun to insert a green tampon-like device every morning for five minutes and do a series of lifts, squeezes and strength tests while my cat watches in puzzlement? No, but it works. What is fun is running for 20 miles and not having to dash to my car to change because I smell of stale urine. What is fun is making myself better, with a little help from technology.
– Guardian service
