Intro: It's Your Health Radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): You may be embarrassed or even a little bit afraid to talk to your doctor about bladder control. Incontinence is so common and can definitely improve with treatment. Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And joining me today is Dr. Mya Levy. She's a urologist on the medical staff at Henry Mayo Newhall Hospital.

Dr. Levy, thank you so much for being with us. This topic is something that, of a certain age, us women talk about amongst ourselves, but it is sometimes a little difficult to bring up with doctors because you're not quite sure if it's embarrassing or not. How common are bladder control issues? I'd like you to explain a little bit about pelvic floor disorders, the type you see. And our patients, do they seem embarrassed to talk to you about it?

Dr. Mya Levy: So in my practice, I would say 100% of the population has a pelvic floor issue, but that's because those are the folks who are coming to see me. But it is incredibly common, and it's not just women. I see men who have incontinence as well, but it is so common with women. And it's a combination of muscle weakness, a combination of hormonal changes that happen as we're perimenopausal and intramenopause and postmenopause, and also damage that happens as a result of childbirth. All of those things together can contribute to bladder control issues. And also, there's just a percentage of people who have really reactive bladders and we don't always know why. So, it's an incredibly common problem. And when folks come to see me, I really try to create an environment because many women, especially my older patients, find it really embarrassing. And I try to create an environment where they feel comfortable talking about it. And my goal is to help people get out of the house and feel comfortable. And I think incontinence can really, for many women, keep you at home or limit your ability to do exercise or go to the grocery store because you're thinking about where's the next bathroom and all those types of things.

Melanie Cole, MS: Well, thank you for that. And one question I want cleared up before we get into this topic and some treatments and things people can do to help themselves. Is this a normal part of aging? You mentioned some causes. You mentioned pregnancy. Some people just have a weak pelvic floor. Men get this. Certainly, it can be a prostate issue. It can be so many different things. But is it, for those others, a normal part of aging?

Dr. Mya Levy: I think that's almost a philosophical question because, for me, while it may be normal, what's most important, is it bothersome? And if the problem is bothersome, even if it's normal, it's still a problem. So, you know, what I try to gauge with people, especially when we're thinking about treatments, is how bothersome is this for you? Because in general, a lot of what I do in the office is not life or death. These are issues that are to help women or men feel better.

Every treatment that we have has risks. So, it's deciding how bothersome is this issue for you, even if you think it's normal. And some women will come to me and they're in diapers throughout the day and they just feel like, "Oh, well, this is just normal." And does that bother you? That doesn't sound normal to me. So, it's trying to gauge bother, I think.

Melanie Cole, MS: Well, that answers my next question about when should someone seek help when it really becomes quality-of-life-limiting, is what I kind of think of. Some of us, we cough, we laugh, we pee a little bit and maybe we even giggle about that because isn't that funny? But when it becomes something that you know you're out skiing, you're out doing something and you have to wear a diaper or you have to go to the bathroom all the time or you just feel really uncomfortable dressing up, then I guess it's time to see you. So, what do you do for us? Let's start with some of the either medications or lifestyle, non-surgical treatments, things you could tell us right off the bat.

Dr. Mya Levy: People come to me and put them into three different categories when it comes to incontinence. And we're just going to talk about women. We're not going to talk about men right now. So, some women come to me and they have what we call stress incontinence. So, that's the incontinence where you cough, you laugh or no sensation or no urge to go to the bathroom and urine just comes out. So, that's one group of women who come to see me. Another group are women where you get that sudden urge out of the blue and you can't make it to the bathroom. And then, there's a good percentage of women who fit into both of those categories, and the treatments are very different for each one of those categories.

So, I first try to figure out what is this woman's primary issue and what is she most bothered by. And so, if it's stress incontinence, so that leakage when you cough, laugh, or sneeze, or you don't have an urge to go, and then all of a sudden you stand up and urine starts coming out. For those women, I recommend doing pelvic floor exercises. And YouTube is a great resource to look at how to do pelvic floor exercises, or many people call them Kegel exercises. And it's really about strengthening the lower core muscles and the pelvic floor muscles. And it's like going to the gym. If you go once a week or you go once a month, you're not going to have improvement. You really have to be dedicated and basically increase the amount of strengthening of those muscles, and increase the number and the time of exercises that you're doing every day. So, a lot of women aren't really successful at doing that solo at home. So, I refer a ton of patients for pelvic floor physical therapy.

Henry Mayo has an excellent pelvic floor physical therapy program, and it's just a great option with no risks in terms of medical side effects. And for treatment options for women who have this type of leakage, so the stress incontinence, I guess we can dive into that a little bit more, but the exercises are really great for that. For women who are bothered by urgency and feeling like you have that sudden urge to go and you can't make it, I talk about different behavioral things that you can do. So, there are different beverages that can give you more urgency and less bladder control. So, anything with caffeine or alcohol in it, you want to avoid those, because those are going to make you make more urine and have more urgency. So, trying to avoid those. And also, trying to drink consistently throughout the day as opposed to chugging a bottle of water and getting back to what you're doing. The faster you drink, the more you're going to have frequency and urgency and not make it to the bathroom. So, those are some things that I recommend folks trying before we do anything more invasive.

Melanie Cole, MS: That was an excellent description, and pelvic floor physical therapy is a great way. It's a relatively new field, but boy, it's helping so many people. And as you said, we're talking about women, but it helps women and men. And Henry Mayo Newhall Hospital has an excellent pelvic floor physical therapy program, so you can look that up.

Now, next, treatments, we do that. We try these lifestyles. We heard what you said. Are there medications? Are there interventional treatments? Because you have so many tools in your toolbox now.

Dr. Mya Levy: I'm always trying to gauge how severe the issue is. And that's primarily how bothered, like how much is this affecting someone's life day to day? And if they're most bothered by that urgency and you get that sudden urge and you can't make it to the bathroom, and avoiding those irritants that we talked about, like caffeine and alcohol, when that doesn't work, I talk about medication. We have medicines that relax the bladder muscles so that you can hold on to more urine, so that you have less frequency and you have more time to make it to the bathroom. And there's a bunch of different medications.

Some of them have side effects that I don't like. Some of them have very few side effects. So, we try to gauge which one would be the best option for you. But medication for folks often works very well. So, that's the first line treatment for what I call urge incontinence or not making it to the bathroom on time with a sudden urge. For stress incontinence, it's primarily not an overactive or an oversensitive bladder, but weakness in the pelvic floor or the urinary sphincter muscle, which is that muscle that we learn to control when we're babies. And as we get older, unfortunately, all our muscles get weaker. So, the treatments that I have as a urologist or someone who specializes in treating incontinence are reinforcing or strengthening those muscles. So, for the urinary sphincter, that muscle we learn to control when we're babies, I have a filler that I use. It's different than a lot of the cosmetic fillers that women might be familiar with, but it's a filler that I inject into the wall of the urethra, and it basically bulks the urethra. And it's a fairly straightforward procedure. I do it at a surgical center though, with sedation because it's uncomfortable, but that's a fairly straightforward procedure that's durable and relatively long-lasting.

We also have surgeries that I do to reinforce the pelvic floor. So, we do what's called a sling and it's basically a hammock of support around the urethra that I surgically implant into patients. And so, those are two treatment or surgical options that I recommend. There's no real great medication that helps with stress incontinence or that muscle weakness incontinence. So, it's really about deciding, are you bothered enough and the physical therapy or the exercises aren't working? Are you ready for a procedure? That's the conversation I have with patients.

Melanie Cole, MS: So, was Botox what you were describing as your first intervention there?

Dr. Mya Levy: No. So, Botox is not filler. So, Botox is a second-line option for urge incontinence. So, urge incontinence, again, is that leakage that you have when you get a sudden urge to go and you can't make it to the bathroom. And that generally is a result of an overactive bladder muscle. So when avoiding caffeine and alcohol doesn't work and trying medication which relaxes the bladder muscle, some of those medications are either oxybutynin or Gemtesa or Myrbetriq. When those medications don't work, Botox is the next step for that. And Botox is a muscle relaxant. So, women use that or men use that in your face to get rid of wrinkles, but what it really does is it relaxes the muscles in your face. So when I inject that into your bladder wall, what it does is it paralyzes or relaxes the bladder muscle and allows you to hold on to more urine and make it to the bathroom on time. So, that's a great option that I do for a lot of patients. But I generally reserve it for folks who medication doesn't work because it is a little more invasive, and it's a procedure that I do in the office that you don't need anesthesia for, but it's uncomfortable, and it's not permanent. It only lasts for about six months. And so, that, I consider an option after medication. So, the filler for stress incontinence or that muscle weakness or urinary sphincter weakness, the filler that I use, my preference is one called Bulkamid. And it's a water-based gel that basically bulks the urinary sphincter and gives you more control there.

Melanie Cole, MS: Wow, that's so interesting. There are so many options available now for women. As we get ready to wrap up, Dr. Levy, this has been enlightening, you've given us a lot to think about. Treatment options, I'd like you to give your best advice for being our own best health advocate, when you feel it's important for women to look to their physician. Whether they start with their primary care and move on to a urologist, or they come right to you, what you want us to know about bladder control, pelvic floor disorders as we age, kind of the lifestyle that we see as we start as younger women all the way through our reproductive years and pre and post-menopausal, because there can be pelvic floor disorders that can happen at all of these different life stages.

Dr. Mya Levy: I think, number one, just getting that information about pelvic floor physical therapy out there. And man, I wish all women did pelvic floor physical therapy before they had babies, after they had babies, just to set them up for success early on. But I think the advocacy part of what you're saying is really important, that we think is normal is not okay in some respects. So, being in diapers throughout the day, you don't have to be. And if it's something that is limiting your life in any way, go see your doctor. Come see me. You know, there are so many different options. And I want women to know that. So, I think that's the most important thing. If you are bothered, if you aren't able to see your grandchildren, if you aren't able to go to the store because you're worried about making it to the bathroom, that is not normal. That means you should see a doctor and get some assistance or see what your options are.

Melanie Cole, MS: Dr. Levy, thank you so much for joining us today and sharing your incredible expertise about something that some of us, I mean, not me, as you can tell, but some people are very embarrassed to discuss. So, thank you so much again. You can find more information at the Free Health Information Library at library.henrymayo.com. And that concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. Please always remember to subscribe, rate, and review It's Your Health Radio on Apple Podcasts, Spotify, iHeart and Pandora. Until next time, I'm Melanie Cole.