Joey Wahler (Host): It affects many women. So, we're discussing urinary incontinence. Our guest is Dr. Will Stone. He's a urogynecologist with FirstHealth of the Carolinas. This is the FirstHealth and Wellness podcast from FirstHealth of the Carolinas. Thanks for joining us. I am Joey Wahler. Hi there, Dr. Stone. Welcome.

George Will Stone, M.D.: Hi. Good morning. Thanks for having me.

Host: Great to have you aboard. We appreciate the time. So first, what exactly is urinary incontinence for those unfamiliar and just how common is it in women?

George Will Stone, M.D.: Sure. So in the most basic sense, urinary incontinence is leakage of urine, inability to in control urine, urine urgency, urine frequency, so not making it to the restroom. And how common is it? I guess it depends on who you ask. Some studies have it as high as 60% of women, 70% of women. And I think that depends very much on the frequency of leakage. And so, if you were to ask, "Do you ever leak?" That's where you probably get 60-70%. If you ask people, "Do you leak on a regular daily basis?" Maybe 10-20%. It's hard to nail down, because we only get these answers if we ask the questions. And I think historically we've been bad at asking the questions, particularly that pertain to women's health.

Host: Gotcha. And we're going to talk a little bit more about that aspect of it in just a moment. But first, women suffer from incontinence more than men, correct? So, why is that?

George Will Stone, M.D.: Yes. More than men in some cases and scenarios. It is very bimodal. What I didn't include in that 10-60% is pregnant women because, in pregnant women, urinary incontinence is very common. And if you look at men over the age of 60, incontinence is fairly common too because you start running into inability to empty and prostate issues and the like.

But if we look at groups as a whole, by and large, women have greater issues with incontinence than men. And some of that is anatomical, some of it is functional. Anatomical, the urethra for a female is only three to four centimeters long. The urethra for a male is that plus whatever the penile length is. And so, there's more of an opportunity for flow to be restricted from urine getting from the bladder to the outside. And then, women have the privilege and the possibility of carrying children and having childbirth, and that can have profound effects, whether you have a vaginal delivery or a C-section on the structures at or around the vagina and some of the support underneath the urethra and the support for the bladder and that can, of course, also affect continence mechanisms.

And so, probably the biggest risk factor is that difference between being able to have a child and not being able to have a child. But then, there are also changes that occur over time with women that men don't have to the same extent. Menopause, the loss of estrogen as a hormone to support tissue health, tissue flexibility, tissue strength, that also greatly affects the risk for incontinence, which typically does increase as women age.

Host: It certainly all makes sense. So basically, it can be very common in women and men, but as you just illustrated for very different reasons. How about the difference between stress incontinence and urge incontinence? What's the difference there?

George Will Stone, M.D.: For most people, the difference is an academic one, because for the patient it's just "I leak," right? It's not so much "I leak for X, Y, or Z reasons." And part of the reason I like to bring them in and see those patients is to figure out the why, right? With stress incontinence, this is when you cough, you laugh, you sneeze, you exercise. And pressure above the bladder is transmitted to the bladder. And that pushes on the bladder, effectively attempting to push urine out through the urethra.

The reason we leak has to do a lot with what's going on with the urethra. When it comes down to it, the urethra is just a floppy tube, right? And it's this floppy tube that normally sits on a pretty solid base of support so that when you cough, laugh, or sneeze, that floppy tube is squished on the base of support. Think of it like a garden hose sitting on the sidewalk, right? It's squished flat. No water comes out because you got the sidewalk. What happens with stress incontinence? It's the loss of the sidewalk. It's like taking that same garden hose and moving it into the tall grass and then stepping on it. Well, it just kind of sinks into the grass. There's nothing pushing up from below well enough to get that to restrict flow so you leak. So, stress incontinence is a structural issue. And for most cases, this isn't all cases, but most cases, we believe it to be a problem with support underneath the urethra.

Urge incontinence is more of a bladder issue or a nerve issue. There's something going on with the bladder's ability to either hold urine and/or listen to the messages that should be coming from the brain controlling urination, right? So, the normal process is that the bladder fills. The bladder's not a smart organ. It's just designed to feel pressure. As that pressure increases, it shoots that signal up to the brain. The brain determines when it's socially appropriate to go to the bathroom, sends that signal down to the bladder when it's go time, and then you're good to go. So, any problem anywhere in that process from bladder filling, sensations being just pressure sensations and not pain sensations that's signaling from the pelvic floor up through the spinal cord, up to the brain and then back down again. Any problem, anywhere along that pathway can lead to bladder overactivity and urgency, which can in turn lead to incontinence.

Yes, they are discreet categories. There is some crossover in them. Many women who present come with mixed urinary incontinence, which is a little of this, a little of that. And usually, in those scenarios, we try to figure out which is the prevailing type of leakage that they experience. Because as you imagine, one is more of a structural issue, the other is maybe a muscular rather, or neurologic signaling issue. The treatments do vary a bit between the two. So often, we try to find the thing that bothers them the most, treat that, and see what remains afterwards.

Host: Gotcha. You touched on this a bit earlier, but to expand on it, Doctor, you mentioned women that are pregnant, women that are going through menopause, any other women that are in a risk factor scenario that makes it more likely for them to experience this?

George Will Stone, M.D.: Sure. There are a number of risk factors associated with incontinence in general. So broadly, age is viewed as a risk factor. Though I'm not sure that age is probably a perfect independent risk factor. I think it's more a proxy, right? And so, what is a proxy for, particularly with women, is menopausal status in a way. As we get closer to menopause and further into menopause, the risk for incontinence-- and I know this is beyond the scope-- but prolapse increases quite a bit. It's likely due to tissue-mediated changes that come from the loss of estrogen, and those become accumulated changes over time. You have estrogen receptors and the urethra, you have them in the bladder, you have them in the vagina. That's that entire kind of area, and the support structures in that area. And so, that certainly can drive it.

Obesity is a risk factor for both stress incontinence and for urgency. Parity, and by parity, I mean the number of childbirths. Certainly, the mode of delivery matters as well too. If someone had cesarean sections versus vaginal deliveries. And potentially even more concerning would be like a vacuum-assisted vaginal delivery or a forceps-assisted vaginal delivery. That said, C-section isn't entirely protective against these risks. And women with C-section history can still get that.

The family, if your family has a history of incontinence, you are much more likely to have a history of it too, which probably makes an argument for maybe connective tissue issues that we inherit how our connective tissues work, that comes from mom and dad. And then, other things like the type of stuff that you eat and you drink, what you do on the weekends; you know, smoking has risks, particularly for urgency; carbonated, caffeinated, spicy foods. We have to remember that everything that goes into our body comes out in one of two ways. We're either pooping it out or we're peeing it out. And so, the bladder is, again-- I'm not picking on the bladder-- it's not smart and it's very picky. It can voice its displeasure in only a couple of ways. And for many people, that manifests as urgency, frequency, needing to go to the restroom.

Host: How about stigmas surrounding this issue, urinary incontinence. Obviously, it can be embarrassing for a patient. So, how do you attack that, work around it, whatever you want to call it in this instance and, therefore, empower women to take charge of their health and realize that they can confide in you?

George Will Stone, M.D.: I think the biggest stigma that we face is that it's normal, right? That, "Oh, you're a mom, leakage happens," "Oh, you've had two kids," that's okay. And that I think it undercuts and undervalues the discomfort and the suffering that people can have from it. You know, if it happens once in a blue moon and it doesn't bother you, that's fine. But I'm not going to gaslight a patient into saying, "Oh, that's not important because you're a mom." I think that happens far too much. Again, with women, you just got to grin and bear it. No, this is something that's very common that people don't want to talk about because it's embarrassing to talk about. And the way that we try to remove the embarrassment is, one, just making it absolutely judgment-free, but two, asking the questions. The most important thing is to ask the questions and to normalize, "Hey, are you having leakage? Are you having urinary leakage" or "Hey, having urinary leakage with intercourse? Are you having bowel leakage?" These are questions that I'd probably ask, or if I were to poll a random group of people, very few of their physicians have ever asked them those questions. And maybe they don't ask them, because then you have to follow it up, right? If they say yes, what are you going to do? But our goal is to ask the embarrassing questions and then follow it up and give whatever treatments the patient chooses to pursue.

Host: Well, speaking of asking questions, you led me beautifully into my next one, just a couple more for you here, Doctor, and that is the biggest one of all probably for those joining us, what can be done about this? What are some of the common treatment options available for women through FirstHealth Urogynecology?

George Will Stone, M.D.: Again, stress is structural; urge is neurologic or muscular. And so, the pathways diverge kind of right off the bat, there is some overlap and the overlap are in these lifestyle behavioral changes that patients can undertake. Keeping in mind that the bladder's picky, trying at least a period of time to avoid carbonated, caffeinated, spicy foods and seeing if that makes a difference, right? Remembering that this is all quality of life stuff. And if it greatly affects your quality of life so much to take the Mountain Dew out of your diet and it's worth it to leak to get that Dew, go for it, right? Like that's patient-driven, that's fine. But if they do see that it greatly affects their urgency, their frequency, well then, heck, we made a good argument for maybe reducing the intake of some of these irritant type of things.

The other thing that we run into often is people are drinking a ton of fluid. There's so much mixed messaging that comes through in medicine in general nowadays, but also when you throw into like TikTok and all these other things, everybody seems to believe they need to drink a gallon of water a day. And outside of some unique circumstances, most people don't need that much. So, reducing fluid intake to a more reasonable maybe 64 ounces or so a day can have drastic improvement for both stress and urge.

Pelvic floor physical therapy or doing pelvic floor muscle exercises is a huge opportunity to treat both stress and urge. So, there's a ton of crossover there. The trick is finding true pelvic floor physical therapists and people that will do the hard work and the appropriate work to get the patients where they need to go. And I would say that unless you're seeing a pelvic floor physical therapist who is doing internal work for you, at least occasionally, we're probably not getting the full benefit of pelvic floor physical therapy. I can't tell you the number of patients that I've seen who come in, say they failed pelvic floor PT or failed pelvic floor exercises. And I check for a Kegel and they can't find the right muscles. And so, yes, you can do this stuff on your own. There are weighted balls, there are Kegel programs you can get for your phone, any number of things. But it's hard to replace having an expert guide you. That's where pelvic floor PT is wonderful.

We have pelvic floor PT at FirstHealth. We have wonderful pelvic floor physical therapists in our office with whom we work closely. And there are resources in the community. But sometimes, it can be helpful to speak with us to help you get plugged into those resources. That's where there's plenty of overlap, and then things diverge.

So for stress incontinence, we have pessaries. There are over-the-counter things that you can purchase, like Impressa devices that go in the vagina, support the urethra, so that people don't cough, laugh, or sneeze some of these may be viewed more as a temporary, adjunct. Other well-fitting pessary can be used for years and years if that's what someone prefers. We also have surgical options like placement of a bladder sling, either one made out of your own tissue or one made out of mesh, urethral support procedures, and even urethral bulking procedures to narrow the opening of the urethra or rather narrow the diameter of the urethra to make it less likely to leak. That's stress incontinence.

On the urge incontinence side, there are medications, there's nerve therapy either through nerve stimulation, like the posterior tibial nerve that's essentially like an acupuncture type procedure where patients come in on a weekly basis, and get nerve stimulation with the small amount of electricity to help affect signaling for the pelvis. There's Botox injections that we can do in the bladder, and even more centralized sacral nerve modulation where we do implantable wires at these sacral nerve roots to affect signaling. Anything that is offered anywhere else in the biggest centers in the country we are doing here.

Host: That last point, very important to note. Folks, we trust your now more familiar with urinary incontinence in women. Dr. Stone, valuable information indeed. Keep up all your great work, and thanks so much again.

George Will Stone, M.D.: Thanks for having me. I appreciate it.

Host: Same here. And for more information, please do visit firsthealth.org/medical-care/urogynecology. If you found this podcast helpful, please do share it on your social media. And thanks so much again for being part of the FirstHealth and Wellness podcast from FirstHealth of the Carolinas.