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Scott Webb (Host): Urge incontinence is a common condition that affects roughly 30 million Americans and though limiting our intake of caffeine and alcohol will save us some trips to the bathroom, there are some new and exciting treatment options to help folks. I'm joined today by Dr. Craig Smith. He's a urologist who's currently overseeing a clinical study for overactive bladder and urinary incontinence.

Doctor, thanks so much for your time today. We're going to talk about urge incontinence, and I'm a guy in his 50s. And so sometimes I have a little bit more urges than other times. So, so it's great to have you on. Great to have your expertise. Let's start there. What is urge incontinence and how does it differ from other types of incontinence?

Craig Smith, MD, FAAP, FACS: Yeah, great question, because, this entity in and of itself is just a tough one. When symptoms such as, uh, I gotta go and I can't get there in time, that's sending off some alarms. Like, oh, man, I, I used to be able to, you know, cut back on the fluids, and I used to be able to know where every washroom is, but all of a sudden, I can't get there in time, and things get a little wet.

That's uncomfortable, and that's when you need help. But the definition really is a sudden, strong, intensity of sensation of void, and it comes on as abrupt and there's not much time between that sensation to go and actually bladder contracting and eliminating. And so it's acute, sudden, strong, urge, sensation to eliminate.

Host: Yeah, I see what you mean, and it's funny, yeah, and I know for me, one of the triggers in needing to go more often as a guy, again, in his 50s, is coffee, caffeine, you know, so if I know that I'm going to, let's say, take a plane flight or something like that, I know to limit my coffee intake, a few hours before I'm going to get on a plane, just because it's inconvenient, you know, to get up and go find the washroom on a plane. Just wondering, they seem obvious, but what are the typical symptoms that patients with urge incontinence experience?

Craig Smith, MD, FAAP, FACS: Yeah, it's that sudden, strong, sense to go and it's guys and gals for actually common but also separate reasons. It's fairly common. So we're talking about something that involves 28 to 30 million Americans. So that's a big number. So we all are in a sense, at risk at some point, but not all get it. But when you have it, it's like, what needs to be done to curtail this?

Host: Right. And as you say that, uh, maybe limiting intake is one of the things we can do, but when we think about the causes and risk factors, it can't be that we're just drinking too many fluids, right? There, there must be some other stuff at work. So maybe you can go through that.

Craig Smith, MD, FAAP, FACS: Right. Well, let's, I think, let's work on that, what you just said, because, you know, what do we do initially when that occurs? Like, if all of a sudden that's you.

Scott Webb: Sure.

Craig Smith, MD, FAAP, FACS: Like, what am I going to do? And it's true, you go to your own personal resources. Were they drinking too much fluid? The more I take in, the more I go. But it wasn't that way when I was younger. And your bladder was a little bit different, it's ability to hold and store. So, you make changes, so you alter what you drink. Let's talk about that a little bit. So, caffeine and alcohol, what does that do? So, both those compounds, when they're ingested, have an effect on the posterior pituitary gland in your brain, which makes you produce less antidiuretic hormone.

Well, those are all big words, but what it means is, at the kidney level, if you have caffeine or alcohol, you're going to produce more urine. So I always tell people, you drink one, you go two. You drink two, you go four. So it's going to make you produce more urine. So that's the accommodation. Like, alright, so I know if I drink this, I'm going, baby.

So maybe I don't, because you're just doing these preparative things. And those are all good things. Those are behavioral modifications for the benefit of your bladder. And so that's to understand that's what's under the hood is a little bit that. So that by taking those two substances in particular, makes you go more urgent or more frequent.

Host: For sure. Yeah, it's so interesting, you know, and of course, while you were answering that question, I was sipping a hot cup of joe, hot cup of coffee, you know, so, you know, it's just this self fulfilling prophecy, I know I'm doing it to myself, I know I'm going to have to go more, you say drink one, go two, I know that's going to happen, but I just can't help it because I just love coffee.

Craig Smith, MD, FAAP, FACS: And it's okay. You know, people like, oh man, I just want to, now you're telling me I can't. I go, hey, you just have to understand you have to pay to play. So, if you don't mind going a little bit more often, have your cup of joe. It's okay, you know, go to Starbucks, but you probably will go a little more often.

That doesn't mean you have a troubled medical condition. It's just a response to that type of ingredient. That's all.

Host: For sure.

Craig Smith, MD, FAAP, FACS: Now, there is sometimes some things under the hood. And so, there are some conditions that lead to overactive bladder, urge incontinence. Sometimes, they're neurologic, where there's two entities that, yes, this leads to this. It's a risk and sometimes they're what we call idiopathic so that you could have this symptom and not have any other true underlying neurologic causes for it. So it's just kind of in and of itself a condition. Let me, if you will, tangent on that too because I'm going to go, I'm going to break it guys and gals.

So for men, so prostates, you got them. And the prostate is tissue that's just in front of the bladder, so the bladder contracts, you're urinating through the prostate gland before it exits out the urethra. In time, as we get older, that prostate gland grows, it just does. And as it grows, it impinges upon the channel between the bladder and the urethra.

As you have resistance, the bladder is a muscle, smooth muscle, it's not striated muscle, it's not like your biceps, it's a smooth muscle, but it's a response to resistance is the same. It gets thicker, stronger. So, as the bladder becomes thicker, stronger, as a result to resistance, it's going to become more urgent, more frequent.

So, it's a muscle getting stronger and it's feeling the sensation to go earlier and sooner as a result of long term resistance against the prostate. So, for guys that are having concerns about urgency frequency, it's all part of the International Prostate Symptom Score of quantifying symptoms to consider treatment of prostatic obstruction to improve bladder symptoms, of which one of them is urinary urge incontinence.

Host: For sure. And I'm assuming then, in addition to patient history, you also do some diagnostic tests, so maybe you can tell listeners exactly how do you diagnose and evaluate patients with the symptoms of urgent continence.

Craig Smith, MD, FAAP, FACS: Right, so when people are coming in, well, a lot of times, one of the main reasons we're coming in to see the urologist, I, you know, doggone it, I was urgent, now I'm wet, you know, what am I going to do? What is it, what do you have there? And how are we going to check it out? What are we going to do?

So, probably the most important thing is a voiding diary. A voiding diary. And what you're going to do is you're going to put on paper, on black and white, you know, what did you drink? How much did you go? Did you have a episode of incontinence. And you'd fill it out for a couple days, ideally even we'll do a three day diary.

It's going to seem like a lot of time and effort, but it helps the individual, the patient, and the doc come together with, you know, how problematic is this? What do we see as far as associations with what you drink and what's eliminated? And events that may occur in other things that correlate with the incontinence.

That's a kind of a cornerstone necessary to the evaluation. So what am I going to do? Oh yeah, I'm going to do a voiding diary. Those are things that for evaluation, if we think that there is, if it's a guy and they're having some issues with potential prostatic obstruction, we've got to take a look, you know, we're going to go through the urethra and look at the prostate and the bladder, assess its health, assess what degree of obstruction that could be leading to the frequency, urgency or urgency counts as far as what we see, does that warrant intervention?

And for gals and guys, is there something in the bladder lining itself that's leading to some urgency and urge incontinent episodes. So let's, take a look. So we look together. These are 15 to 20 second procedures in the office with local anesthetic. There's no prep. Come in, take a look and go home.

And often it's suggested that the patient bring a spouse. So as they're akitng this in, the spouse can look at what we see as well, so we can have further discussion. It will be easier for them to share with their spouse.

Host: Yeah, I see what you mean. And we talked about limiting our intake, of course, so alcohol, caffeine. Me, personally, I don't want to live in a world where I can't drink caffeine, but that is a separate podcast. Uh, it's my happy place, you know, whether I'm podcasting or not. But, uh, just wondering then, in addition to knowing what our triggers are and cutting back when possible, what are some of the other treatment options for urge incontinence?

Craig Smith, MD, FAAP, FACS: Right. Behavioral modification, timed voiding. So, even going before you need to go. So this is a little, a little bit awkward transition of an additional step, but it's setting a time, like go on the odds and evens every 2, 4, 6, 8 or 1, 3, 5, 7, just making an attempt to go to the bathroom. It's like, why do I, I don't have to go.

Right, but you're going before that urge episode happens where you couldn't get there in time.

Host: Right before it an emergency, right?

Craig Smith, MD, FAAP, FACS: Off your bladder. So yeah, because there's, there's anatomic obstruction, like in guys, there's not much anatomic obstruction in gals, and there's a lot of women that have urge and urge incontinence, but for them to hold, like they need to go on their holding. Put the big squeeze on, that's also making your bladder work harder too because it's contracting against that type of functional resistance. So going to the bathroom before you even have an episode or going in a specific time interval is helpful. So that's time voiding.

 People often try those things at home, just for things they can do. So what are steps that we can do in the office? There's bladder relaxants that are very good to allow the bladder to hold more. And have less urgent episodes that would lead to incontinence. And there was an old school of medications, anticholinergic, I know it's a big word, but that was the common medicine, but it had side effects of dry mouth and constipation.

It came out with a newer batch called beta agonist, new class of meds. They're effective, they're good. But just that said, only about 15 percent of people that start medications are actually on them in a year, and that's usually, sometimes there's side effects on the medication, sometimes it's cost is the issue.

And just the idea of taking a pill is not something that one, somebody typically wants to do indefinitely. And in two years, only 5 percent of people are on meds. So what else outside of medicines are effective? And mainly we're then working at restoring the function between the brain and the bladder.

So one kind of additional input as far as why do things occur in urgency and urge incontinence; it's a brain bladder thing. So, the brain in general is sending inhibitory messages, hold, stop, store messages to the bladder, and there's some discoordination between those two organ systems. So, the bladder goes, I want to contract and empty, the brain goes, hold on there, stop, I'll tell you when you need to go, you can hold.

So, but what if there's a disconnect? What if there's some reason that message isn't happening too well? We can neuromodulate, we can stimulate the nerve pathways between the brain and the bladder, which down regulates overactivity. Fascinating.

Host: Yeah, it really is.

Craig Smith, MD, FAAP, FACS: We're, we're putting some simulation into sacral nerve roots.

There's even a therapy called REVI, which is new, where we're simulating a posterior tibial nerve, so a little chip in your ankle. It's going to do the same thing. It's providing energy to the nervous system, which down regulates overactivity. And these therapies are effective; 70, percent to 80 percent of neuromodulation in the sacrum is effective. 80 percent of people having a neuromodulation in the ankle is effective. So the ankle is new, it's very new. The neuromodulation has been out since the late 1990s as far as sacral. There is, outside of a procedure where we're implanting something, you can have something even placed in the ankle called posterior tibial nerve stimulation.

It's like a little, little needle that's not much more than an acupuncture type needle. And that stimulates a nerve that also can affect that. It's done for about half hour 40 minutes, once per week, but it's a lot of back and forth to the clinic. So that's why they came up with an implantable so you didn't have to come back and forth to the clinic as much with even better results.

That's REVI. So there is neuromodulation. Another thing to slow down bladders that are too busy is a place in Botox. You got a Botox, there's a lot of use for Botox. And yes, even the bladder can be slowed down by doing a cystoscopic inspection of the bladder and injecting some Botox in the bladder.

And just find out what quantity is best for you to get the results you need. So, so that is another effective therapy for management of urgency and urge incontinence.

comments.

Host: It's really amazing. I mean, sure it starts with, you know, cutting back on things that we know are triggers and maybe going before we really have to go, but awesome to learn that there's so much cool, new, you know, medical stuff, technology out there to help folks. I just want to finish up. And this has been really educational for me as a guy in his fifties, of course, and probably for everybody else.

But, if folks are hesitant to talk to you or any doctor about urge incontinence; what would be your words of wisdom? How do we get them into the office?

Craig Smith, MD, FAAP, FACS: Yeah, well, just the big thing is just let them know they're not alone. You're not alone. And a lot of people are doing the same thing. They're driving and looking at which is the next turn off to get to a, to a bathroom, toilet. So it is a quality of life issue. And I think what, what has occurred is people have thought, well, hey, you know, that's just part of what happens, you know, get a little bit older, bladder gets little crazy, and that's what you just have to deal with.

And that's part of life. It's not, it's not a part of normal life. And we have answers. We have some ways to work through it with you so just to come and get evaluated, you know, especially for those that have, have a good realm of practice. So it's not just pills only, it's, there's pills, we can work with physical therapy.

We didn't talk about that too much, but that's also a means of gaining improved tonicity and health in the function of the, of the bladder, but also some innovative things that are really making a difference in people's lives. You know, you put one of these neuromodulation devices, they go to 80 percent dry. That's one happy camper. I mean, that's like, wow, I didn't know like this would work. Those are big smiles. That makes you come to work, you know, seeing people do well like that.

Host: Yeah, yeah. It's really amazing. Really educational. Great stuff today. Thank you so much.

Craig Smith, MD, FAAP, FACS: Really appreciate it.

Host: And for more information, go to dulyhealthandcare.com. And if you found this podcast helpful, please share it on your social channels and check out our full podcast library for additional topics of interest. This is Duly Noted, a health and care podcast from Duly Health and Care.