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Melanie Cole (Host): Many American men and women suffer from urinary incontinence and they don't tell anybody because they may be embarrassed, or they may think nothing can be done, so they suffer in silence. My guest today is Dr. Leon Plowright; he's a urogynecologist at the Carle Foundation Hospital. Dr. Plowright, tell us a little bit about what you see as far as prevalence and societal impact of incontinence. What's different now about what we know about it, and what we know about treatments available?

Dr. Leon Plowright, MD (Guest): I get quite a few patients who they come in to see us in the office, and I sense there's a little bit of reluctance to talk about the condition. So that is, I believe, the focus of our urogynecology field initiative now, is to raise awareness. To raise awareness that it's quite often that we see this type of condition, it could be as high as up to 50% of adult women experiencing urinary incontinence. Now the problem is there's, again, a degree of embarrassment. There's a great deal of impact on the quality of life, sexual function, and the burden that it requires- the burden on caregivers.

So what we're trying to do is really reach out to our communities locally, regionally, and talk about the condition, and talk about the treatment options. Now the treatment options have always been available, but we're moving more and more to create more- I guess minimally invasive approaches. So we have a little bit more to offer to our patients; non-surgical and surgical options, and we sort of just climb up the ladder depending on where each individual is in terms of the severity of their leakage, and what they've done before.

Host: Is incontinence a normal part of aging? Because that may be part of that discussion, and people are afraid or embarrassed, and they think it's just something they have to endure, and that it's a normal part of aging.

Dr. Plowright: Absolutely. I think that's one of the misconceptions. While it does- the severity of urinary incontinence does increase with age, it's not something that should be accepted as part of the aging process, because we have things or we have interventions that can assist patients with dealing with this condition. So again, part of what we're trying to do is just to educate the public that while age is one of the components that kind of lends itself to incontinence, we really need to push to seek treatment and seek help earlier rather than later.

Host: How would you advise other providers, whether they are primary care providers or geriatric providers; how would you advise them to start, and when would you advise them to start that discussion, to ask the questions, "Are you having incontinence? Do you suffer from leakage?"

Dr. Plowright: I think there is some reported urinary incontinence as early as twenty years of age, but I believe that the primary group is probably around the age of forty. I think that's the time where you sort of have to start that conversation. And there are really easy questionnaires out there that you can use to sort of raise the conversation within your general office visit. And once you raise the conversation once or twice, then maybe the third time around, you may say, "Do you want to see someone for that? There's a urogynecologist or a urologist that specializes in women's care, or even a pelvic floor physical therapist." Those are places that you can really get a starting point, and then move from that point on.

Host: I love that idea, that you're offering up the other providers that specialize in this particular situation. What does treatment look like these days, and start with obviously the non-invasive treatments. You mentioned pelvic floor physical therapy. Tell us about that.

Dr. Plowright: Right. You know, I think a lot of people have a great deal of misconception of pelvic floor therapy, or they confuse pelvic floor therapy with Kegel exercises. A lot of my patients, they come in and they say, "I've been doing pelvic floor exercises." I ask them, "What have you been doing?" They say, "Kegel exercises." And then we do an examination, and I'm checking their muscle strength within the pelvic region, and they're contracting, but they're not contracting their pelvic floor muscles. They're actually contracting their gluteal muscles. So to me, Kegel exercises is a start. But really, where we want to get you to is a pelvic floor physical therapist because they're able to really give you the feedback that's necessary for you to understand the intricate muscles within the pelvic floor, and understand how to activate its contraction and its relaxation.

So my approaches, as far as non-invasive kinds of things that we can do, first is to raise an awareness of the pelvic floor, how it functions, talk about the function of the bladder, how you fill your bladder, how you empty your bladder, and just having a good understanding of that helps you to figure out how to kind of time your voids.

Some people who have urinary incontinence, if we teach them how to time their voids to say, "Hey, even though you may not feel the need to go to the bathroom, try to void every two to three hours, or every three hours." That tends to decrease the rate of urinary incontinence, and then the next step is being cognizant of the fluid that you're taking in. So sometimes patients, they drink a lot of fluid, and they don't realize that what goes in has to come out. So what I tend to do for those people that I have the suspicious that they're drinking quite a bit, more than the normally expected amount, is I give them a bladder diary. So the bladder diary helps them to understand what's really happening with them, because they may think they're having leakage that's not controllable by the amount of fluid that they drink.

Now that's not to say that if you have urinary leakage you should stop drinking fluid, it's just to say just be cognizant of the fact that if you drink a whole lot, you may have accidents, and you may find a need to go to the bathroom quite often. So those are kind of some simple things that we do; bladder diary, timed voids, pelvic floor physical therapy. And then as we move up the ladder, there are other things that we can introduce patients to. There is a device that can be purchased over-the-counter. It's a device called a Poise Impressa, and it's not a tampon, and it's not necessarily a pessary either, and we'll talk about a pessary. But it's a way in which we can place a device inside of the vagina, and that device kind of supports the urethra. So when you have an increase in intra-abdominal pressure such as with laugh, and cough, or sneezing, then there's some support underneath the urethra, and that tends to help you to maintain continence.

That device I typically use for patients that most of their leakage occurs during time of physical activity such as exercise, running, but otherwise when they're walking about on the day-to-day basis, they don't really have much incontinence. So that's a really neat device to have at your disposal, and I have quite a few patients who really want to use that device as opposed to moving forward with surgery.

The next level up is a pessary. You can use a pessary, it's like a diaphragm-like device we place inside of the vagina, and it has a little knob at the tail end, and that knob tends to support the urethra, and that may decrease the amount of incontinence episodes just as the Impressa does- the Poise Impressa. So those are mainly the main options that we have for patients.

Now there are other sophisticated options, but we tend not to use them here. There are some urethral plugs. I haven't seen those on the market here in the US, so I don't really offer those to patients. And moving up from that platform, or from that site, we're talking about surgery, and surgery can be a long list of different things.

Host: What about medicational intervention? People even see in the media medications available to help with incontinence. Where do those fit into this timeline, Doctor?

Dr. Plowright: Yes, I'm glad that you bring it up because the conversational piece just a moment ago was mainly addressing stress urinary incontinence. Now stress urinary incontinence is the most predominant type of incontinence that we see. Now there is incontinence that is caused by urinary urgency and frequency and also urge incontinence. And that kind of lies in the category of what we call overactive bladder, or detrusor instability. So that is where medications really play a role.

We often start patients on what is called an anticholinergic medication, and that tends to decrease the contractility of the bladder, and that maintains urinary continence. So again, we're talking about two different types of incontinence. One is overactive bladder and one is stress urinary incontinence. The stress urinary incontinence we talked about. The overactive bladder is what we're talking about now, and that's where medications play a role.

Now there are a couple of caveats to medication use. The overactive bladder medications, they're anticholinergic, so they have some side effects. They affect not only the bladder, but they affect they eyes, the mouth and so forth, so they can result in dry mouth, dry eyes, and constipation. So you want to warn your patients about this. The additional thing is glaucoma. If you have closed angle glaucoma, these are medications that we're not to prescribe for those kinds of patients because that can worsen their condition.

The other medication on the market is beta-3 agonist, it's called Mirabegron, and this medication doesn't have the side effects of dry mouth, dry eyes, or constipation, but it should be used with caution with individuals with elevated blood pressure that's not controlled. If it's controlled, then you can use the medication. Studies have shown that this medication may raise the blood pressure. A newer study has shown that the combination of the two medications - of beta-3 agonist and an anticholinergic medication - may be more efficacious than one alone, and the two medications that were studied was Mirabegron and Vesicare. So that's also an option that you can- provided that insurances will allow, you can offer to your patients, because I believe it's now FDA approved for that reason.

Host: What great information and good points all, Dr. Plowright. Thank you for clearing so much of that up for us. Wrap it up, what would you like other providers to take away from this? As you stressed a number of times, awareness is the key. Awareness of the treatment options out there, and getting people to discuss it, to talk about it. Give us your best advice.

Dr. Plowright: My best advice is to start early. Once you have that conversation early, you start with the screening at the age of forty or so, you start that conversation, and then we can move them to the pipeline, and the pipeline is this - either send them to a urogynecologist or a pelvic floor therapist, and then we get the conversation started, and then we can work together to get them to where they need to be. But I think it's the upfront conversation that is needed well before it's often had, and I often see patients in their eighties, seventies, and nothing has been done, and quite frankly, at that time my hands are tied because there are so many risk factors to maybe medication, or surgery, or things of that nature that makes it difficult for me to get them the treatment that they need. There's a lot of caregiver burden that we have to kind of get through, but if we started early, we'll be able to mitigate all of that. We'll get them in the pipeline earlier, sooner rather than later. And we talked about the medications - the anticholinergic medications - those are just a start, but there has been some evidence of dementia memory problems with those patients. So we sort of don't want to linger with the medication throughout their lifetime. We want to kind of continue the conversation and get them to third line therapy before it's too late for us to do so, and maintain some of their cognition. So the takeaway is screen, screen, and screen early.

Host: What a great key message, Dr. Plowright, thank you again for joining us, and for informing other providers of the importance of screening, talking with their patients, and getting an early start so that you're not limited in your treatment options. Thank you again. You're listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle's sponsored educational activities, please visit www.CarleConnect.com. That's www.CarleConnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for tuning in.