Selected Podcast
Getting Help for Incontinence
If you're too afraid to ask about urinary and fecal incontinence, hear the answers to your questions from Genesis Urogynecologist, Mitesh Parekh.
Featuring:
Mitesh Parekh, M.D
Dr. Mitesh Parekh is a urogynecologist with Genesis Urogynecology. He is board-certified in female pelvic medicine and reconstructive surgery. He has more than 20 years of experience treating women’s pelvic health issues. Dr. Parekh is recognized by Medtronic, a medical device company, as a member of the InterStim™ Center of Excellence Program. The recognition means Dr. Parekh demonstrates exemplary use of the InterStim™ system and a commitment to patient care for those with symptoms associated with overactive bladder, fecal incontinence and non-obstructive urinary retention. Transcription:
Scott Webb: Incontinence is a fairly common condition. And the good thing is there are many treatment options, including the InterStim device. And joining me today to tell us more about Incontinence and his approach to care is Dr. Mitesh Parekh. He's a urogynecologist with Genesis.
This is Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. I'm Scott Webb. Dr. Parekh, it's so great to have your time today. And when I think about incontinence, I sort of feel like that's something that I think sort of intuitively maybe most of us kind of know what that is, but maybe not all the details. So it's great to have an expert on, to talk through some of this and get all the details. So let's start here, doctor, what is incontinence and are there different kinds?
Dr. Mitesh Parekh: Incontinence is any involuntary leakage of urine or bowel. And there are different types of bladder as well as bowel incontinence. As far as bladder incontinence is concerned, we classify them typically in three main subtypes. There is a type that's known as stress urinary incontinence. And generally this type of leakage happens with any sort of physical activity such as coughing, sneezing, lifting, bending, pushing, pulling, exercising, cetera. There's a second type of leakage, typically known as urge incontinence or also known as overactive bladder. And this type of leakage generally happens with needing to go to the bathroom. Medically, this is defined as urgency to go. So typically, person will say they leak on their way to the toilet. They just can't get there fast enough. There's a third type of leakage that has both of these components. So they suffer from stress as well urge incontinence and hence, it's known as a mixed incontinence. So these are the three main subtypes.
There's some other subtypes that are not commonly referred to. So one of them is known as a functional incontinence. So functional incontinence happens to folks who may have some sort of physical impairment, maybe they had a knee surgery or back surgery. Now, before when they needed to go to the bathroom, those 30 seconds, they could make it, but because of their pain or walker, now suddenly they cannot make it. So that's known as a functional incontinence. And there's also another type of incontinence known as overflow incontinence. These patients typically don't have ability to empty their bladder. So bladder just gets distended to the point where the pressure builds up and it's greater than the pressure their urethra generates, so at some point urine constantly dribbles, that's known as overflow incontinence. So these are the main types of incontinence for bladder.
Scott Webb: All right. So listening through and good to know the main types and the subtypes. And I guess I'm wondering, when someone suffers from incontinence, is that generally a result of behavior, lifestyle? Is it genetics, family history? Can it be a sort of a myriad of things?
Dr. Mitesh Parekh: Short answer is all of the above. I'm a urogynecologist, so I just treat females. In females, this is largely attributed to childbirth and genetics. Lifestyle factors also matter lot. So folks who smoke and chronically cough, they tend to have more stress incontinence type of issue because muscles get weak over the time. Folks who are constipated chronically have similar issue. Patients who drink more than usual amount of caffeine or alcohol. Caffeine and alcohol acts as a diuretic, and they tend to have more frequency, urgency, overactive bladder type of issue. So short answer is yes, all of those factors play a role.
Scott Webb: Yeah. So what are the options for treating incontinence and can the same treatments work for fecal incontinence?
Dr. Mitesh Parekh: So as far as urinary incontinence, there's lots of different treatments available. Now, first job that I have to do is to figure out what's bothering the patients. So patients may have one or two or different types of incontinence all in one, but they may not be bothered. So not everybody is equally bothered. So if it's not bothering them, generally speaking, it doesn't do any harm to you except for maybe skin conditions, that sort of stuff. So if they're not bothered, then we generally try not to overtreat. But if they're bothered, then once we decided whether they're bothered by stress or mixed type of incontinence, then treatment is directed accordingly.
So stress incontinence, there are treatment options such as doing Kegel exercises, making the pelvic floor muscles stronger, so it keeps the urethra shut better and reduces the amount of leakage during activity. There are couple of medications for that. They're not FDA approved for that purpose, but may keep the urethra shut better. Overall, they work in 50% of the cases and generally it's a month-long trial. There are certain devices that we fit in the vagina that supports a urethra and if a urethra is supported better, it can stay shut better. And again, that can reduce amount of stress incontinence. There also some injections that can be done in the urethra in the office that can keep urethra shut better and reduce the amount of leakage. And then there's some surgical options. There are surgical option for stress type of leakage that can be performed in 20 minutes, outpatient type of surgeries with minimal of anesthesia and that can give the patient 90% chance of making that type of leakage go away. So for stress incontinence, those are the general treatment options. There are some other not so common treatment options that are employed. There are other operations that can be done also.
For urgency type of incontinence or overactive bladder, first and foremost, we recommend lifestyle changes. So if patient is drinking excessive amount of fluid, we recommend they cut back to 64 ounces a day or less of total fluid intake and to limit their caffeine and carbonated drinks to 16 ounces or less out of that 64 ounces and to perform their Kegel exercises to keep the muscle strong, so they have better ability to make it to the bathroom when that urgency hits.
Scott Webb: Sure. Yeah.
Dr. Mitesh Parekh: And then the next treatments generally tends to be medications. And there are seven, eight different FDA-approved medication for urgency problems. Generally, I quote that if you do all of that, you can improve things by 60% to 80%.
Now, there are some other advanced options when medications don't work, then we rely on other therapies. One particular therapy is something called InterStim therapy. It's actually a pacemaker type of device for bladder. It works on the nerve that comes from the back and innervates the bladder. It's something that's done in two steps. First step, we put a wire down and patient will typically go through a trial for a week or two with an external stimulator or pacemaker. And if that trial is successful, patient gets good relief, then a couple of weeks later, we put a little battery underneath the skin. Both steps are performed on an outpatient basis and can be performed under local anesthesia, and they're not big to do type of surgeries.
And there are also nerve stimulation type of treatment that's done in the office and Botox injections. So those types of therapies are done when medication is not adequately relieving patient's symptoms. And of course, if a patient has mix symptoms, then we treat whatever is the most bothersome symptom first. So if it happens to be urgency, then we go the urgency route. And if it happens to be stress, then we go the stress route. I hope that answers your question.
Scott Webb: It really does. And it's just great to hear that you have so many, we'll call them tools. You have so many tools in your tool belt and so many options. So you really talk to the patients, you get a good patient history, what's going on, check on the behavior, lifestyle. And then, you have so many options available, including the InterStim device, which is really cool. I do want to ask you though, is it the same treatments for fecal incontinence?
Dr. Mitesh Parekh: So the only treatment that works on both types of incontinence at the same time is the InterStim device. So that therapy is approved for urge urinary incontinence and fecal incontinence as well as retention of the urine. So out of all the treatments we talked about, that aside from performing Kegel exercise and then making muscles strong, it's the only thing that would improve both types of leakage. And by the way, that's known as double incontinence. So there are a significant number of patients who have urinary as well as fecal incontinence, and that's known as a double incontinence.
Scott Webb: Well, good to know that the InterStim is sort of, you know, one-stop shopping, if you will. If somebody does have the double incontinence, then the InterStim is the obvious, you know, option to me in listening to you today. And for patients who believe that they're suffering from urinary or fecal or the double, is it okay for them to just kind of work with our family doctors or really should they see someone like yourself? Should they see a specialist?
Dr. Mitesh Parekh: So it all depends on the primary care physician. So, these days, everybody's living longer. So they have multiple medical problems such as diabetes, hypertension that consumes a lot of the primary care physician's time. And there are treatments that we mentioned such as, you know, instructing somebody on Kegel exercising or lifestyle changes or medication. All those tools are available to primary care docs and some primary care docs will go down that road before they refer the patient, and some will refer the patient as soon as patient says, "I have this problem. What can you do for me?" So it really depends on the primary care physician.
Scott Webb: Yeah. I see what you're saying. And you mentioned referrals there. I'm assuming to see someone like yourself, a urogynecologist, that referral really is necessary, right?
Dr. Mitesh Parekh: Really not, because as a gynecologist, we can be primary care physicians for the ladies. And for that purpose, you don't need any referral. So being a gynecologist, female patients don't really need any referral to come and see me. Many patients just come in from word of mouth and they just make the appointment directly.
Scott Webb: Sure. Well, that certainly makes it easier. This has been really educational today. Great to learn more about incontinence and the different treatment options, including InterStim. As we wrap up doctor, what would be your takeaways? You know, I think that incontinence sounds to me like one of those things that a lot of people suffer from, that they live with. And you know, I'm sure you want them to know that it's fairly easily diagnosed. There's lots of treatment options and there's every good reason to come see you, right?
Dr. Mitesh Parekh: That's exactly the point. In old days, and even today, many ladies kind of suffer in silence, if you will. They think it's normal part of aging and there's nothing that can be done for incontinence. We can't make everything go away, but we can generally make things a whole lot better. So most ladies after the treatment they say, "I should have done this 10 years ago." So there are options, no need to suffer in silence.
Scott Webb: Couldn't agree more. I have the good fortune of speaking with experts like yourself. And I keep hearing the same thing, which is just because you're older, it doesn't mean that these things are normal, natural, or that you have to live with them, right? You don't have to suffer in silence. We have doctors, we have specialists, we have medicine, we have InterStim. You know, "Come see me," right?
Dr. Mitesh Parekh: That's exactly right. If it's bothering you or taking quality of your life away, there are treatments at the minimum you can try.
Scott Webb: Absolutely. Always worth a try. And as we talked about earlier, lots of tools in the tool belt. So doctor, thanks so much for your time. You stay well.
Dr. Mitesh Parekh: Okay. Thank you. You too.
Scott Webb: And for more information, go to genesishcs.org. And thanks for listening to Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. If you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.
Scott Webb: Incontinence is a fairly common condition. And the good thing is there are many treatment options, including the InterStim device. And joining me today to tell us more about Incontinence and his approach to care is Dr. Mitesh Parekh. He's a urogynecologist with Genesis.
This is Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. I'm Scott Webb. Dr. Parekh, it's so great to have your time today. And when I think about incontinence, I sort of feel like that's something that I think sort of intuitively maybe most of us kind of know what that is, but maybe not all the details. So it's great to have an expert on, to talk through some of this and get all the details. So let's start here, doctor, what is incontinence and are there different kinds?
Dr. Mitesh Parekh: Incontinence is any involuntary leakage of urine or bowel. And there are different types of bladder as well as bowel incontinence. As far as bladder incontinence is concerned, we classify them typically in three main subtypes. There is a type that's known as stress urinary incontinence. And generally this type of leakage happens with any sort of physical activity such as coughing, sneezing, lifting, bending, pushing, pulling, exercising, cetera. There's a second type of leakage, typically known as urge incontinence or also known as overactive bladder. And this type of leakage generally happens with needing to go to the bathroom. Medically, this is defined as urgency to go. So typically, person will say they leak on their way to the toilet. They just can't get there fast enough. There's a third type of leakage that has both of these components. So they suffer from stress as well urge incontinence and hence, it's known as a mixed incontinence. So these are the three main subtypes.
There's some other subtypes that are not commonly referred to. So one of them is known as a functional incontinence. So functional incontinence happens to folks who may have some sort of physical impairment, maybe they had a knee surgery or back surgery. Now, before when they needed to go to the bathroom, those 30 seconds, they could make it, but because of their pain or walker, now suddenly they cannot make it. So that's known as a functional incontinence. And there's also another type of incontinence known as overflow incontinence. These patients typically don't have ability to empty their bladder. So bladder just gets distended to the point where the pressure builds up and it's greater than the pressure their urethra generates, so at some point urine constantly dribbles, that's known as overflow incontinence. So these are the main types of incontinence for bladder.
Scott Webb: All right. So listening through and good to know the main types and the subtypes. And I guess I'm wondering, when someone suffers from incontinence, is that generally a result of behavior, lifestyle? Is it genetics, family history? Can it be a sort of a myriad of things?
Dr. Mitesh Parekh: Short answer is all of the above. I'm a urogynecologist, so I just treat females. In females, this is largely attributed to childbirth and genetics. Lifestyle factors also matter lot. So folks who smoke and chronically cough, they tend to have more stress incontinence type of issue because muscles get weak over the time. Folks who are constipated chronically have similar issue. Patients who drink more than usual amount of caffeine or alcohol. Caffeine and alcohol acts as a diuretic, and they tend to have more frequency, urgency, overactive bladder type of issue. So short answer is yes, all of those factors play a role.
Scott Webb: Yeah. So what are the options for treating incontinence and can the same treatments work for fecal incontinence?
Dr. Mitesh Parekh: So as far as urinary incontinence, there's lots of different treatments available. Now, first job that I have to do is to figure out what's bothering the patients. So patients may have one or two or different types of incontinence all in one, but they may not be bothered. So not everybody is equally bothered. So if it's not bothering them, generally speaking, it doesn't do any harm to you except for maybe skin conditions, that sort of stuff. So if they're not bothered, then we generally try not to overtreat. But if they're bothered, then once we decided whether they're bothered by stress or mixed type of incontinence, then treatment is directed accordingly.
So stress incontinence, there are treatment options such as doing Kegel exercises, making the pelvic floor muscles stronger, so it keeps the urethra shut better and reduces the amount of leakage during activity. There are couple of medications for that. They're not FDA approved for that purpose, but may keep the urethra shut better. Overall, they work in 50% of the cases and generally it's a month-long trial. There are certain devices that we fit in the vagina that supports a urethra and if a urethra is supported better, it can stay shut better. And again, that can reduce amount of stress incontinence. There also some injections that can be done in the urethra in the office that can keep urethra shut better and reduce the amount of leakage. And then there's some surgical options. There are surgical option for stress type of leakage that can be performed in 20 minutes, outpatient type of surgeries with minimal of anesthesia and that can give the patient 90% chance of making that type of leakage go away. So for stress incontinence, those are the general treatment options. There are some other not so common treatment options that are employed. There are other operations that can be done also.
For urgency type of incontinence or overactive bladder, first and foremost, we recommend lifestyle changes. So if patient is drinking excessive amount of fluid, we recommend they cut back to 64 ounces a day or less of total fluid intake and to limit their caffeine and carbonated drinks to 16 ounces or less out of that 64 ounces and to perform their Kegel exercises to keep the muscle strong, so they have better ability to make it to the bathroom when that urgency hits.
Scott Webb: Sure. Yeah.
Dr. Mitesh Parekh: And then the next treatments generally tends to be medications. And there are seven, eight different FDA-approved medication for urgency problems. Generally, I quote that if you do all of that, you can improve things by 60% to 80%.
Now, there are some other advanced options when medications don't work, then we rely on other therapies. One particular therapy is something called InterStim therapy. It's actually a pacemaker type of device for bladder. It works on the nerve that comes from the back and innervates the bladder. It's something that's done in two steps. First step, we put a wire down and patient will typically go through a trial for a week or two with an external stimulator or pacemaker. And if that trial is successful, patient gets good relief, then a couple of weeks later, we put a little battery underneath the skin. Both steps are performed on an outpatient basis and can be performed under local anesthesia, and they're not big to do type of surgeries.
And there are also nerve stimulation type of treatment that's done in the office and Botox injections. So those types of therapies are done when medication is not adequately relieving patient's symptoms. And of course, if a patient has mix symptoms, then we treat whatever is the most bothersome symptom first. So if it happens to be urgency, then we go the urgency route. And if it happens to be stress, then we go the stress route. I hope that answers your question.
Scott Webb: It really does. And it's just great to hear that you have so many, we'll call them tools. You have so many tools in your tool belt and so many options. So you really talk to the patients, you get a good patient history, what's going on, check on the behavior, lifestyle. And then, you have so many options available, including the InterStim device, which is really cool. I do want to ask you though, is it the same treatments for fecal incontinence?
Dr. Mitesh Parekh: So the only treatment that works on both types of incontinence at the same time is the InterStim device. So that therapy is approved for urge urinary incontinence and fecal incontinence as well as retention of the urine. So out of all the treatments we talked about, that aside from performing Kegel exercise and then making muscles strong, it's the only thing that would improve both types of leakage. And by the way, that's known as double incontinence. So there are a significant number of patients who have urinary as well as fecal incontinence, and that's known as a double incontinence.
Scott Webb: Well, good to know that the InterStim is sort of, you know, one-stop shopping, if you will. If somebody does have the double incontinence, then the InterStim is the obvious, you know, option to me in listening to you today. And for patients who believe that they're suffering from urinary or fecal or the double, is it okay for them to just kind of work with our family doctors or really should they see someone like yourself? Should they see a specialist?
Dr. Mitesh Parekh: So it all depends on the primary care physician. So, these days, everybody's living longer. So they have multiple medical problems such as diabetes, hypertension that consumes a lot of the primary care physician's time. And there are treatments that we mentioned such as, you know, instructing somebody on Kegel exercising or lifestyle changes or medication. All those tools are available to primary care docs and some primary care docs will go down that road before they refer the patient, and some will refer the patient as soon as patient says, "I have this problem. What can you do for me?" So it really depends on the primary care physician.
Scott Webb: Yeah. I see what you're saying. And you mentioned referrals there. I'm assuming to see someone like yourself, a urogynecologist, that referral really is necessary, right?
Dr. Mitesh Parekh: Really not, because as a gynecologist, we can be primary care physicians for the ladies. And for that purpose, you don't need any referral. So being a gynecologist, female patients don't really need any referral to come and see me. Many patients just come in from word of mouth and they just make the appointment directly.
Scott Webb: Sure. Well, that certainly makes it easier. This has been really educational today. Great to learn more about incontinence and the different treatment options, including InterStim. As we wrap up doctor, what would be your takeaways? You know, I think that incontinence sounds to me like one of those things that a lot of people suffer from, that they live with. And you know, I'm sure you want them to know that it's fairly easily diagnosed. There's lots of treatment options and there's every good reason to come see you, right?
Dr. Mitesh Parekh: That's exactly the point. In old days, and even today, many ladies kind of suffer in silence, if you will. They think it's normal part of aging and there's nothing that can be done for incontinence. We can't make everything go away, but we can generally make things a whole lot better. So most ladies after the treatment they say, "I should have done this 10 years ago." So there are options, no need to suffer in silence.
Scott Webb: Couldn't agree more. I have the good fortune of speaking with experts like yourself. And I keep hearing the same thing, which is just because you're older, it doesn't mean that these things are normal, natural, or that you have to live with them, right? You don't have to suffer in silence. We have doctors, we have specialists, we have medicine, we have InterStim. You know, "Come see me," right?
Dr. Mitesh Parekh: That's exactly right. If it's bothering you or taking quality of your life away, there are treatments at the minimum you can try.
Scott Webb: Absolutely. Always worth a try. And as we talked about earlier, lots of tools in the tool belt. So doctor, thanks so much for your time. You stay well.
Dr. Mitesh Parekh: Okay. Thank you. You too.
Scott Webb: And for more information, go to genesishcs.org. And thanks for listening to Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. If you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.