Intro: Duly Noted, a Health and Care podcast is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners reimagine and better understand an extraordinary health and care experience.

Jaime Lewis (Host): Stress incontinence is a subject that many women feel uncomfortable talking about, even though one in three of them will be affected by it in their lifetime. Dr. Sarah Martin is a Board Certified Female Pelvic Medicine and Reconstructive Urologist, and she's going to shed light on how female stress incontinence and bladder control can impact women's lives. She'll discuss the causes and symptoms of stress incontinence, as well as available treatment options to help women get back to living their best life. This is Duly Noted, a health and care podcast from Duly Health and Care. I'm your host, Jamie Lewis. Dr. Martin, studies show that one in three women experiences stress incontinence at some point in her life. What is stress incontinence and how is it affecting so many women?

Sarah Martin, DO: Stress incontinence is when a woman coughs, sneezes, laughs, lifts up her baby, does a squat, even can going from sitting to standing, and then she's leaking urine. I like to tell patients what stress incontinence is, is it's the urethra or the outlet misbehaving. So it's a very complex issue actually.

And there's something called the integral theory that looks at it. So not only for your urethra, do you have a sphincter, that can cause stress incontinence, which is called intrinsic sphincter dysfunction; you also have your pelvic floor that is supporting your urethra and if that pelvic floor becomes weak, the urethra can become very hypermobile and this can also cause stress incontinence. So there's not really just one thing causing stress incontinence sometimes. And many women get this confused sometimes with urgency incontinence.

Urgency incontinence is a completely different entity, and that is when it's the bladder misbehaving. So for stress incontinence, what we can do as urologists is we see patients in the office and we really try to determine what they have, if they have stress incontinence, or if they have urgency incontinence, or if they have a mixture of both.

And honestly, most women do have both types of incontinence, which is called mixed incontinence. Then we like to ask these women which one is more bothersome, and when we find out which one is more bothersome, that's the one that we treat first.

Host: Well, I know that when I think of stress incontinence, I think of it in relation to childbirth. Does it only affect women who have given birth or are there other causes?

Sarah Martin, DO: So stress incontinence, there's multiple risk factors. So risk factors for stress incontinence, one of them is vaginal delivery, as well as pregnancy. So not only, even if you have a C-section, you are stills till at risk of having stress incontinence. And that's because that pelvic floor can kind of stretch out as your body changes with the changes in pregnancy.

But I see women all the time who are like, I never had children. Why am I still peeing my pants? The reason is, is that there's multiple other risk factors as well. Smoking is a risk factor, obesity is a risk factor, chronic heavy lifting is a risk factor, as well as chronic constipation. All these things affect the pelvic floor by kind of changing the musculature down there and can affect how you have stress incontinence. It's also if your mom has stress incontinence, this can also predispose you as well.

Host: Let's say I'm experiencing all or any of those symptoms, when should I seek treatment?

Sarah Martin, DO: Seek treatment when it bothers you. I have women that go through one panty liner a day and they honestly cannot handle it. It's very, very bothersome to them. They're very embarrassed. I have other women that see me when they're soaking through five diapers a day, and they're just seeking help. So if something bothers you, there's always something that can be done, and that's especially true for stress incontinence. As women, we constantly suffer in silence and are like, this isn't that bad, or everybody has it, I can live with it. Well, no, you really don't have to, there is easy things that we can do for it. So if it's bothersome, I think you should get treatment.

Host: Is there any specific information a woman should be tracking to bring in to her doctor's appointment?

Sarah Martin, DO: No, I think the most important thing to do is before you come to see a urologist or talk to your doctor about it, is think about when you're leaking. A lot of times when I see women in the office, it's the first time anybody's ever asked them when they're leaking and they say to me, well, what do you mean I leak all the time?

So really trying to focus on, am I leaking with oh my gosh, I have to go to the bathroom right now, or am I leaking while I'm doing activity? And if you're not sure, I recommend if you're sitting there and you notice yourself leaking, that's not activity. Whereas if you notice your pad's more wet when you're really active throughout the day and walking around a lot, those are all really important things for a doctor to know.

Host: Do you have any prevention tips, I guess, for patients to follow to help avoid stress incontinence?

Sarah Martin, DO: With stress incontinence, what I would recommend is to try to stop with all the pushing and try to stop with vaginal clenching is what a lot of my colleagues will say. Trying to prevent constipation, not pushing when you're urinating, really taking your time and learning vaginal relaxation techniques. Pelvic floor physical therapy is just an absolutely wonderful tool for women to utilize. Not only does pelvic floor physical therapy show you how to relax your vagina, so that you're not pushing, you're not ruining your pelvic floor; it also will teach you how to hold the appropriate muscles when you do cough, sneeze or laugh so that you don't leak or to suppress those urgency feelings that you get.

So a lot of women are like, all I do is Kegels and that's it. Well then their pelvic floor is really tight and that makes it a lot different. So it's actually a very complex issue. And I do encourage every woman, especially women after they deliver a child to do pelvic floor PT and really learn about their bodies.

Host: Aside from PT and Kegel work, are there other common treatments for stress incontinence?

Sarah Martin, DO: You can do a pessary. A pessary is not the most comfortable thing for a lot of women. And what a pessary is, is it's a small silicone, basically like a donut. And we put it inside your vagina and it acts as a bolster against your urethra. And then it prevents you from leaking.

There's also something called the Impressa tampon that is over the counter. Some women will come in and tell me, you know, Dr. Martin, I only leak when I run, I go for a run and I'm drenched, but I never leak. This patient is the perfect candidate for the Impressa tampon. It's basically a tampon that you put in. And again, it acts as that bolster against the urethra and you put it in before you go for a run and then you can take it out afterwards. And this works really well for those women. Now those are the more conservative treatment options that we can do.

As far as surgical options, the two surgical options for stress incontinence that we can do. One is a sling. So a sling is kind of our gold standard. Efficacy is about 90 to 95% and it lasts about 20 years. It's a small surgery that we do it usually like a surgery center takes about 30 to 45 minutes. And you start feeling like yourself in about five days. You just have a small incision in the vagina, and then two small incisions either, right at your pubic bone, or on the other side of your legs, depending on what your physician, likes to use for a sling.

The restrictions, everyone asks me, well, what about the downtime? There is no heavy lifting, strenuous exercise or intercourse for four weeks. But other than that, you start feeling, like I said, pretty good after about five days. Now, I think it's really important for patients to understand the risks of a sling.

It is amazing and it works great, but there is a 10% risk of a sling being a little too tight. If this were to happen, it's something you should talk to your doctor about immediately because we can loosen it. There's also a 1% risk of injury to the bladder, bowel, or urethra because I tell patients that is where I'm working.

Another risk in especially postmenopausal females is they can have a little bit of that mesh eroded through the vagina. This is less than 5% and if it happens, we can either just snip this little piece of mesh or use a vaginal estrogen cream. So I like to give my patients everything so that they understand fully well going into the surgery, what can happen.

Now, that being said, those risks are all really low and most women are very, very happy with this. The next option is something called Bulkamid. Bulkamid is an injection into the urethra. And this is really the first injectable agent that has had really good data and literature to help with subjective cure of stress incontinence. And so I do these at my surgery center under local. It takes about 15 minutes and what Bulkamid is is it's a polyacrylamide gel that's about 98% water and I inject it into the urethra and it acts as kind of a bolster in the urethra. It helps to coap tight the urethra together for that sphincter that I talked about.

So this helps with intrinsic sphincter deficiency, and then it helps when you cough, sneeze, or laugh, and it prevents you from leaking. In the literature, efficacy of Bulkamid at five years was about 70 percent. This was compared to the sling at 90 percent, but Bulkamid was found to be non inferior to the sling.

So women were still very happy with it. I do a lot of Bulkamid in my practice. I do think it matters the injector, how many they've done. I would say approximately about 80% of my women are almost completely dry, if not completely dry with Bulkamid. And what they like about it is there's no downtime. You can kind of do whatever you want to do the next day.

 And the risk factors are just a urinary tract infection. And that's because I'm injecting something into the urethra. But other than that, it's a pretty low risk, easy procedure.

Host: Well, Dr. Martin, thank you so much for sharing the facts about how women can identify and treat their stress incontinence. This has been really helpful. I'm your host, Jamie Lewis, and this has been an episode of Duly Noted, a health and care podcast from Duly Health and Care. For more information on women's stress incontinence and the treatments available, visit dulyhealthandcare.com.