The Laugh Test: When Incontinence Starts Controlling Your Life

By Dr. Georgine Nanos, MD, MPH | Board-Certified Family Physician, Kind Health Group, Encinitas, CA

I can usually tell before anyone says a word about a bladder.

A woman mentions she stopped running and switched to walking, and she quit the trampoline class, and she has a rule now about where she sits at a show so she can get out, and she went back to pads for everyday, not for her period, just for everyday, and she says all of it as scheduling. Preferences. Getting older. Then I ask one question about laughing and the whole thing comes out at once.

She did not stop running because she lost interest. She stopped because of what happens at mile two.

What the Laugh Test Is Actually Measuring

The National Institute of Diabetes and Digestive and Kidney Diseases defines it about as plainly as it can be defined. Stress incontinence happens when an action such as coughing, sneezing, laughing, or physical activity puts pressure on the bladder and causes urine to leak.

That is the whole test. Something raises the pressure inside your abdomen, and the support system underneath does not hold, and you leak. There is no urgency involved, no warning, no feeling that you need to go. It is mechanical.

Urge incontinence is a different animal, where a sudden strong need arrives and you cannot hold it long enough to get there. And plenty of women have both at once, which has its own name, mixed incontinence, and which matters because the two halves respond to different things.

So when a woman tells me she leaks, my first question is whether it happens when she laughs or when she is putting the key in the front door. Those are two different problems wearing the same coat.

How Common This Actually Is

Researchers analyzed national survey data from 2015 to 2018 covering 5,006 women and found that 61.8 percent reported some urinary incontinence, which works out to roughly 78 million adult women in the United States, and 32.4 percent of all women had symptoms at least monthly. Those results were published in Female Pelvic Medicine and Reconstructive Surgery in 2022.

Among the women who had it, 37.5 percent had the stress type, 22 percent had the urgency type, and 31.3 percent had both. And 22.1 percent of all adult women had incontinence rated moderate or worse.

The same analysis found the figure had climbed from earlier estimates of 38 to 49 percent using the same national survey between 1999 and 2004, which the authors attribute to an aging and heavier population.

Now hold those two facts next to each other. More than six in ten women, and almost nobody talking about it. That gap is the actual clinical problem. Women assume they are the outlier in a room where they are the majority.

And the Office on Women's Health says the part I want in bold: urinary or bladder incontinence is not a normal part of the aging process, and there are treatments that work.

The Part That Costs the Most

The leaking is not what takes the life. The rearranging is.

NIDDK actually names this in its own symptom list, and it is the line I quote to women constantly: you may have bladder control problems if you limit your activities in fear of not making it to a bathroom in time.

Read that as a diagnostic criterion, because that is what it is. Not the volume. Not the frequency. The rearranging. If you have mapped the bathrooms on your regular walk, if you have a seat rule at the theater, if you skipped the hike, if you have stopped picking up your kid because of what happens when you do, you have a condition, and it has already started charging you.

And the losses are never dramatic enough to raise an alarm on their own. One class. One trip. One hobby. It comes off in slices, and nobody notices a slice, and then a woman is sixty and has not been in a pool in eleven years and cannot point to the day she decided.

What Is Actually Behind It

NIDDK lists what weakens the pelvic floor in women: pregnancy and childbirth, trauma or injury, pelvic organ prolapse, and menopause. Chronic coughing does it too, which is why NIDDK connects smoking to stress incontinence directly, through the cough rather than through anything mysterious.

The national survey analysis found incontinence more likely with increasing age, a body mass index of 25 or higher, prior vaginal birth, anxiety, depression, and functional dependence. Age over 70, a body mass index over 40, and vaginal birth had the strongest associations.

The same study is worth reading for what it did not find. Incontinence was not associated with diabetes, education level, prior hysterectomy, smoking status, physical activity level, or current pregnancy status in their models. I point that out because women blame themselves for a list of things that turns out not to be the list.

Think of the pelvic floor as a hammock rather than a valve. Hammocks fail at the anchors and along the weave, and childbirth, tissue change after menopause, and years of pressure from above are what work on both.

What the Evidence Says to Try First

A Cochrane review published in 2018 pooled 31 randomized trials involving 1,817 women across 14 countries, comparing pelvic floor muscle training against no treatment or an inactive control.

Among women with stress incontinence, 56 percent of those doing pelvic floor muscle training reported cure, compared with 6 percent in the control groups, and the reviewers rated that particular outcome as high-quality evidence. For cure or improvement together the numbers were 74 percent against 11 percent. Across the trials, training cut leakage episodes by about one per 24 hours, and adverse events were rare and minor where they were reported at all.

Two honest caveats, because a number this good invites overselling. The cure comparison rested on four trials and 165 women, which is a small base under a large-sounding result. And most follow-up in these trials ran under twelve months, so the reviewers said plainly that long-term effectiveness still needs more research.

The reviewers concluded that pelvic floor muscle training belongs in first-line conservative management. That is where this starts, and NIDDK says the same, adding bladder training on a schedule for the urgency component and noting that a physical therapist trained in pelvic floor therapy will get you more out of the exercises than doing them alone.

Which is the piece most women miss. Kegels done wrong are not a smaller dose of the right thing. A meaningful number of women bear down when they think they are lifting, and nobody has ever checked.

There are in-office options beyond home exercise, and they are a real conversation, and they are a different article than this one. Start with what is proven and cheap and available to you this month.

When to Be Seen Sooner

NIDDK lists symptoms that need care right away rather than at your next physical: being unable to pass urine or empty your bladder, urinating eight or more times a day, blood in your urine, and symptoms of a bladder infection including painful urination. Those can signal something other than a weak pelvic floor and they get evaluated on their own timeline.

What You Can Do This Month

Keep a three-day bladder diary. Fluids in, trips to the bathroom, every leak, and what you were doing when it happened. Three days of that tells me more than the appointment does.

Sort your leaks into two piles. With a cough, laugh, sneeze, or lift goes in one. With a sudden urge goes in the other. Bring both counts.

Write down what you have already given up. The class, the run, the trip, the trampoline, the front row. This is the part women leave out and it is the part that decides how aggressively we treat.

Ask for a referral to a pelvic floor physical therapist and ask specifically for an internal assessment of whether you are contracting correctly. Getting the technique confirmed is worth more than another year of guessing.

And say it in the first two minutes of the appointment, not the last. Bring it up before the door handle.

To every woman who has been quietly redesigning her life around a bathroom and calling it a personality change: you did not get old and you did not get careless. You have a condition that six in ten women share, most of them in silence, and it responds to treatment. You are allowed to want your life back exactly as it was.

Frequently Asked Questions

What is stress urinary incontinence?

The National Institute of Diabetes and Digestive and Kidney Diseases defines stress incontinence as leaking that occurs when an action such as coughing, sneezing, laughing, or physical activity puts pressure on the bladder. It happens without any preceding urge to urinate, which distinguishes it from urgency incontinence. Many women have both types at once, known as mixed incontinence.

How common is urinary incontinence in women?

An analysis of 2015 to 2018 National Health and Nutrition Examination Survey data covering 5,006 women, published in Female Pelvic Medicine and Reconstructive Surgery in 2022, found that 61.8 percent of adult US women reported some urinary incontinence and 32.4 percent had symptoms at least monthly. Of those affected, 37.5 percent had stress incontinence, 22 percent had urgency incontinence, and 31.3 percent had mixed symptoms.

Is leaking urine a normal part of getting older?

The US Office on Women's Health states that urinary or bladder incontinence is not a normal part of the aging process and that there are treatments that work. Age is associated with higher rates, but common does not mean expected or untreatable.

Do pelvic floor exercises actually work for stress incontinence?

A 2018 Cochrane review of 31 randomized trials involving 1,817 women found that 56 percent of women with stress incontinence who did pelvic floor muscle training reported cure, compared with 6 percent of those receiving no treatment or an inactive control, an outcome the reviewers rated as high-quality evidence. That specific comparison drew on four trials and 165 women, and most trial follow-up was under twelve months, so long-term effectiveness is less well established. The reviewers concluded pelvic floor muscle training belongs in first-line conservative management.

When should leaking be evaluated urgently?

NIDDK advises seeking care right away for inability to pass urine or empty the bladder, urinating eight or more times a day, blood in the urine, or symptoms of a bladder infection such as painful urination. These can indicate conditions other than pelvic floor weakness, including infection or bladder disease.

What should I bring to an appointment about bladder leaking?

A three-day bladder diary recording fluid intake, bathroom trips, each leak, and the activity that triggered it. Separating leaks that follow a cough, laugh, or lift from leaks that follow a sudden urge helps direct treatment. It is also worth listing activities you have stopped doing, since NIDDK counts limiting activities out of fear of not reaching a bathroom in time as a symptom in its own right.

Written by Dr. Georgine Nanos, MD, MPH, founder of Kind Health Group in Encinitas, CA. More on The Kind Revolution podcast. Related: Leaking when you laugh, Why kegels alone don't work, and The pelvic health problems women don't talk about.