My heart goes out to you.  It's a really embarrassing and difficult problem. There are some things to try besides surgery and your doctor should be willing to discuss them with you.  Please don't be afraid to talk with the doctor about it.  You never have to submit to surgery without your full consent; so don't worry about anyone making you have it.  I am assuming that your incontinence is not caused by a physical deformity such as might be caused by large fibroids.  I had fibroids which were causing problems and therefore surgery was my best option.  Karen suggested muscle strengthening. This is usually the first suggestion and it is certainly the one with the least possible bad side effects.  Find out about Kegel exercises.  They exercise the muscles you use when you start and stop a stream of urine. Actually any exercise you can do that will work that whole general area can help.  You can concentrate and work them anytime and anywhere - just watch how you compose your face when you do it :-) 

There are also various hormonal therapies for incontinence.  There is something called the Estring which is a ring impregnated with estrogen and worn in the vagina to dose that area and some women find that it brings the tissue and muscle back to a more normal function.  If you don't want to use the Estring, there are creams and gels to insert into the vagina to have a similar effect.  If over a reasonable time, these things don't help, then you consider surgery and, yes, surgery doesn't always work.  I hope that some other women will post on this subject.  Many of the perimenopausal symptoms are transitory and when one lets up another takes its place.  It would be good news if some could post that this is one of those transitory symptoms.  It's always possible and you would only have to wait it out, using absorbent pads until the problem goes away on its own. 

I wish you well, 
fiona 
Update Nov 2001:
Extract from a medline abstract of yet another analysis of the HERS trial. The conclusion is the opposite of what is generally claimed, at least for older women.
Postmenopausal hormones and incontinence: the Heart and Estrogen/Progestin Replacement Study.
Grady D, Brown JS, Vittinghoff E, Applegate W, Varner E, Snyder T; The HERS Research Group.
University of California, San Francisco, San Francisco, California 94105, USA. [email protected]
CONCLUSION: 

Daily oral estrogen plus progestin therapy was associated with worsening urinary incontinence in older postmenopausal women with weekly incontinence. We do not recommend this therapy for the treatment of incontinence.

I read about collagen treatments for incontinence in a  magazine and wondered about it. So when I saw this mentioned recently in a Reuter's news story I copied it. I just found it again now. The URL may be stale by now. (It is - Tishy) 

Side Effects Of Incontinence Therapy

NEW YORK (Reuters) -- One out of five women given collagen injections to treat urinary incontinence end up having complications, according to a report in the March issue of the Journal of Urology. 

"Contrary to previous reports that periurethral collagen injection is complication-free, we found an overall incidence of 20% risk of complications in any given individual," reported Lynn Stothers and colleagues from the University of British Columbia, Vancouver, Canada. 
 

Since the late 1980s, periurethral collagen treatments have been considered safe and effective in the treatment of women with stress urinary incontinence, the leakage of urine with laughing, coughing, or physical activity. Cow-derived collagen is injected into the area surrounding the urethra, partially blocking the flow of urine. 

In the study, the researchers looked at 337 women with stress urinary incontinence who received between 1 and 6 injections of collagen. At about 32 months after the procedure, 20% reported complications. 

The most common and serious side effect, reported by 13% of women, was a new onset of urinary urgency with incontinence. Seventeen women, or 5% reported blood in the urine lasting less than 48 hours, and five needed emergency room treatment for the bleeding. About 2% had episodes of urinary retention, requiring catheterization. Three women reported flaring of the skin test site within two days of the injection, indicating that they were having a reaction to the cow collagen -- which had originally been tested on a paatch of skin. Two of those women experienced persistent joint pain. 

While the other side effects are short-lived and respond to treatment, the high incidence of urgency with incontinence was unexpected, and its cause is unclear, the researchers wrote. 

The data "suggests that the probability of a worsening clinical outcome of continence status should be part of the preoperative information provided to patients considering collagen injection," they concluded. 

SOURCE: Journal of Urology (1998;159:806-807)

[ me again] 

I believe these collagen injections are quite expensive. In my area they are not covered by insurance and they the collagen costs about $500.00 per injections and up to 6 injections may be needed. 

Kathryn 

Homemaker J has given some good advice.  I would especially work on pelvic floor exercises, and drink lots of cranberry juice.  It might be a good idea to be checked for a possible bladder infection, too.   Twice now, when the incontinence was worse than usual, it turned out that I had a bladder infection, and when that was treated, the incontinence decreased. 

My next suggestion may seem counter-productive, but I found that if I increase my fluids intake it actually seems to help the incontinence, even though it makes my bladder fill up more often.  I suspect that maybe the reason it seems to help is that it dilutes the urine, reducing the irritation that may contribute to the incontinence. 

If you only leak a little bit at a time, you might try what I've been doing.  I buy a large package of (inexpensive) panty liners, and just wear one all the time.  If I leak, I immediately change it for a fresh one.  Of course, if I leak a large amount that overflows the liner, then I have to change my underwear, too (and outer clothes if it goes that far).  And any time urine gets on my skin (or pubic hair) I wash it off. I keep a box of baby wipes in the bathroom for this (which I tear in half, to save money), but washcloths work fine, too. That seems to keep the odor and irritation under control.  I'm also fastidious about keeping my skin dry -- with all that moisture, I tend to get rashes and irritations.  But don't use talc -- it just seems to make irritations worse, and now is known to be linked to ovarian cancer. 

(Urologychannel.com is "comprised of hundreds of practicing urologists from Sacramento, California to Istanbul, Turkey. In addition, the channel is supported by renowned medical organizations such as the Lahey Clinic, as well as by corporate underwriters including Boston Scientific/ Microvasive™, Medtronics™, American Medical Systems™, Medtronic™/Interstim™ and Bard™." It follows the Health on the Net code)

---

For further information call, fax, or write to: 
THE SIMON FOUNDATION FOR CONTINENCE 
P.O. Box 835 
Wilmette, Illinois 60091 
Fax: 847-864-9758 Phone: 847-864-3913 

More URLS for information on The Simon Foundation can be found by using a web search machine like Alta Vista ( http://www.altavista.digital.com/ ). 
Here are a couple of them: 
http://www.unitedwaydenver.org/iris/of0nozi8.htm
http://www.simonfoundation.org/html/c/12-3/two.htm

Another thing you might check is whether your medication might be contributing to incontinence. (I'm not familiar with it, so have no idea.  You could check the drug information papers that come with it, or ask your pharmacist, whether incontinence is a side-effect. Diuretics, which are often prescribed for high blood pressure, can contribute to incontinence.)

http://www.wellweb.com/acct/treat.htm This article discusses a lot of treatments for incontinence, and gives a fairly thorough explanation of Kegel exercises.  Unfortunately, it discusses surgery first (but you can skip that part and go on to the rest of the article instead): 

There also may be support groups available. 

(inserted by Tishy) for email lists, try http://www.egroups.com/search?query=incontinence&submit=Search

http://housecall.orbisnews.com/databases/ami/convert/003978.htmllists a few national organizations, and also suggests checking your phone book under "social service agencies." 

For what it's worth, here's some information given in a story form: http://www.awhonn.org/lifeline/incontin.htm

I haven't read most of them yet, but there is a whole list of articles on incontinence at http://search.info.nih.gov/s97is.vts(The same info can be reached by doing a search at  http://www.nih.gov/ ) 
The first article is pretty good (except that I object to the push to get everyone with incontinence to seek medical treatment.) http://www.niddk.nih.gov/health/urolog/pubs/uiwomen/uiwomen.htm
(Some of the others are less useful to a lay person.  But if you have the stamina to wade through them, there may be other good articles too.) 
Information on Kegel exercises: http://www.healthanswers.com/database/ami/converted/003975.html
http://obgyn.uihc.uiowa.edu/Patinfo/urogyn/kegel.htm
http://www.dua.com/sep97.htm
For the scientific-minded, the following discusses a study of pelvic floor muscles and Kegel exercises: 
http://www.teleport.com/~ibis/notekege.html
http://incontinet.com/hoppatin.htm

Here is a URL for a product designed to help women develop pelvic muscle control -- http://www.pos2000.com/  (I am not connected with these products in any way-- just found them during a search for "Kegel exercises.") 
http://Incontinet.com/home.htmThis page also features a product.  They have some interesting information as well (including links to over 260 web pages about incontinence). 

Lianne