Cheryl Martin (Host): Many women suffer in silence because it's inconvenient and can be embarrassing. What is it? Urinary incontinence, UI, loss of bladder control. It affects twice as many women as men. But there is some good news. There are options, both surgical and nonsurgical, for getting your life back and restoring bladder control. You'll learn about them coming up.

This is Mountain Medicine, the official podcast of Northern Inyo Healthcare District. I'm Cheryl Martin. With me to discuss female incontinence and what can be done about it is Dr. Jeanine Arndal, an OB-GYN with NIHD's Rural Health Women's Clinic. Dr. Arndal, so glad you're on to discuss this condition that's common among women.

Dr Jeanine Arndal: Thank you. It's good to be here.

Cheryl Martin (Host): What causes urinary incontinence, loss of bladder control?

Dr Jeanine Arndal: Well, the way that our bottom is supposed to function has a lot to do with the bony anatomy, the muscular anatomy, and some of the support ligaments of the pelvis. And although the bony anatomy doesn't change very much over our lifespan, the muscular part of pelvis and the ligaments all can change with previous pregnancies, with age, with anything that increases pressure into that area, like obesity or chronic constipation. So when those areas are under a lot of strain or pressure through those things, they can weaken over time. And that's why issues with incontinence and pelvic support worsen over our lifespan.

Cheryl Martin (Host): So does that also explain why we see more women with this condition than men, because of pregnancy and childbirth and menopause?

Dr Jeanine Arndal: Yes, for sure. Pregnancy and previous vaginal delivery are one of the biggest risk factors.

Cheryl Martin (Host): What are some of the symptoms of UI?

Dr Jeanine Arndal: So generally, this is something that can start off pretty slow and gradually progress over time. It's not unusual for women who have recently had a baby in the last six months to come into the doctor's office and, just because of the proximity to delivery, they're still having some incomplete healing of their pelvis. And so they might mention that they're having a little bit of leakage with coughing or sneezing. And then most of the time, these things will get much better six to eight months after delivery. By that time, the healing from delivery is done. So any leakage of urine that people might still have is something that's likely to stay with them, and that will continue to kind of worsen over time.

There are things that we can do that can help with that. And so a lot of times when these women are starting to have mild symptoms after delivery. We recommend things like pelvic floor strengthening. A lot of times people have heard of Kegel exercises, and so we would encourage that. If there has been damage to the ligaments or we could talk about torn ligaments during delivery, those are things that aren't going to necessarily get better with Kegels. And so if it's been more than six to eight months after a delivery, and there's still some symptoms of urinary leakage, then that's a good time to seek out some attention.

Cheryl Martin (Host): So what if you are an older woman and you start noticing the leakage?

Dr Jeanine Arndal: So if you are having any leakage symptoms, it's a good idea to go in and get investigated. I think sometimes people are very nervous that either resources aren't available or resources are going to be very embarrassing or expensive. And so really, the first thing is to come into your doctor's office and kind of talk about the type of leakage or when you're having leakage. Sometimes treatment is as simple as just doing a urine culture. Sometimes women will have urinary leakage just because there's an ongoing chronic urinary tract infection that can be treated so easily with something like just antibiotics.

Cheryl Martin (Host): Doctor, you've already mentioned a couple of non-surgical. What are the other treatment options, nonsurgical and surgical?

Dr Jeanine Arndal: Real quickly, I just want to break down there's different camps of incontinence. One is one that people are very familiar with, especially we're talking about after babies and those kind of things where you might be trying to go running or jump roping, coughing, sneezing, or laughing. There's this increase of stress into that area of the pelvis, and it causes a little bit of leakage at that time. That is called stress urinary incontinence.

The other type of leakage that is really common is when women have a full bladder and they're trying to get to the bathroom, if they can't get there fast enough, they'll notice leakage along the way. And that is typically known as the overactive bladder syndrome or people see commercials and it's they got to go, got to go, got to go. So with overactive bladder, that's generally thought of as a spasm of the bladder muscle. So if you think bladder as like a giant balloon that's supposed to just fill up and allow itself to be filled up, and then give you a signal that you need to go to the bathroom and then it waits until you sit on the toilet to start emptying itself. That's the way the bladder should function. But with overactive bladder, something is making the bladder a little bit more likely to spasm as it gets full. And so for treatment of that specific issue, most of our treatments are either bladder retraining or behavioral therapy or using medications to help relax the bladder in that situation, so it's not spasming and not wanting to empty before you're sitting on the toilet. So for overactive bladder, having leakage on the way to the toilet when your bladder is full, generally, that can be pelvic muscle strengthening, behavioral therapy or retraining the bladder, and then also medications that can help with bladder spasms.

For the other type of urinary incontinence, which is stress incontinence, where you're leaking if you have a little bit of coughing, sneezing, laughing. For that, we're mostly going back to that idea of pelvic support, how can we get better support in the pelvis to really counteract that stress that's happening. And so that is generally with pelvic muscle strengthening like Kegel exercises. We often send women to physical therapy because Kegel exercises, although most women have an idea of what that is in their head, doing them properly is so important to getting good results. So pelvic floor physical therapy and Kegel exercises.

To recreate or correct the pelvis support, we can use things like pessaries. Pessaries are something that not all women can conceptualize. It's basically a silicon disc most commonly that is placed inside the vagina that helps correct the pelvic support and that's something that you would talk to your doctor about. You would come in for a physical exam and then a pessary would be chosen that's the best size and shape to help you with your pelvic support issues. So a pessary is one option, and then the final option is surgical correction of prolapse and all of these things are things that we do here at Northern Inyo Hospital. There are additional layers of therapy and support. If these things are not what the patient is interested in or if we've tried these things and they haven't sufficiently helped with the incontinence, there are specialists outside of our community that sometimes are consulted or can be helpful in other treatment options as well.

Cheryl Martin (Host): So how do you determine, you've covered a little bit of this, which one is best? Do you sort of start on the low spectrum and then move your way up when dealing with patients?

Dr Jeanine Arndal: I definitely always just talk to the patient. It's my goal to usually start with the least invasive, least expensive therapies, because sometimes that's all that's required. But as those things are tried and we haven't reached the level of correction that we're looking for, then we kind of go up the ladder. So we talked about an evaluation with a urine culture, making sure that there's not an infection going on that could be easily treated. We're looking at the support of the pelvis with the exam, and then we're talking to the patient.

Sometimes my patients want to skip step two, step three. They don't want a pessary. They don't want physical therapy. They've been dealing with this long enough that they just want to go directly to surgical corrections. Something that they don't have to continue to maintain like physical therapy or maintain like a pessary. And so we just listen to the patients. If the patient isn't sure what they want to do, I like to just go one step at a time, like you're going up that ladder, again from the least expensive, least invasive treatments to something that might be a little bit more helpful if they haven't reached that level of correction yet.

Cheryl Martin (Host): Now, is surgery available at any age?

Dr Jeanine Arndal: Well, definitely people's age and their functional status and their health is going to be important when discussing surgery. I have some 80-year-olds in my practice that are amazingly healthy and would be able to undergo surgery without problems. Sometimes the type of surgery or the length of surgery that we choose might be different based on somebody's age and other health conditions. But in general, we just want to make sure that we get the right treatment for the right person and we keep all of those things in mind, how well they would tolerate surgery.

Cheryl Martin (Host): Does any patient come to mind who had been suffering with leaking urine for years and you remember what it was like and what they said after they had a procedure?

Dr Jeanine Arndal: So I do get that all the time, both because there's this stigma associated with leaking urine, people don't always want to talk about it or they're embarrassed to talk about it. And then, also, I get this idea that people think, "This is just normal. Women just go through this and so I just need to deal with it because everybody else is just dealing with it. I don't want to complain about it or mention it." But I would say to everybody, and when women are in my practice for any reason for getting their well woman exams or whatever, I always ask, What's going on with your bladder? Any pain? Any leakage? Any problems?" Just because I want people to feel empowered that they can talk about it. And I want them to know that there are treatments available.

Even though this is common, it doesn't mean that it's normal. There are huge costs from incontinence that people pay both emotionally and financially. Emotionally, this can cause depression. Emotionally, it can keep people away from their loved ones or from doing the things that they would like to do because of embarrassment. They don't want to have leakage or an accident when they're out trying to do things with their family. But also financially, the cost of things like pads and incontinence underwear, all of those kind of things can also be really challenging for people as well.

So I would say, absolutely, the first step is just to start talking about it, hearing about the options that exist and then getting treatment started. I have had so many patients that said, "If I only knew" or "Why didn't I do this five years ago or 10 years ago?" So if there is any symptoms that you're having, it's a great time to discuss what the options are and to stop paying the emotional and financial costs of incontinence.

Cheryl Martin (Host): Well, that's the purpose of this podcast, to encourage women and to let them know that there is hope. And I'm so glad you pointed out that this is not a normal part of aging.

Dr Jeanine Arndal: There is a certain amount of stress in the pelvic floor that can be caused by a lot of different things. Everybody has their own pelvic anatomy and their own functions. This is also an important part of our body for sexual function. We have a lot of women with bladder issues and sexual function issues, pain in the pelvis, support issues where there feels like there might be some lack of support or something trying to bulge through the opening of the vagina. All of these things are kind of linked together. So although we really wanted to focus on leaking urine in this talk today, I also just wanted to encourage women if you're having any problems with your pelvic floor, our office is a great, safe place to just come and talk about it. All of these other things have treatments associated with them too that can be hugely helpful. Get you back to living the life that you want to live, being active, and we can get those started for you right away.

Doctor, thank you so much for sharing these options for improving the quality of life for women experiencing leaky urine. That was Dr. Janine Arndal, an OB-GYN with NIHD's Rural Health Women's Clinic. To learn more, call 760-873-2602. That's 760-873-2602. Or visit our website, nih.org. That's N-I-H dot O-R-G.

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