Maggie McKay (Host): Welcome to Flourish, a podcast from Prisma Health. I'm your host, Maggie McKay. Joining us today is Dr. Johnny Wright Jr., urogynecologist, to discuss urinary incontinence. Thank you so much for being here today.

Dr. Johnnie Wright, Jr.: Thank you for the invitation, Maggie.

Host: Let's dive right in. What exactly is urinary incontinence, and how common is it, especially among women?

Dr. Johnnie Wright, Jr.: Urinary incontinence is defined as the involuntary leakage of urine, meaning the bladder leaks when a person doesn't want it to, okay? It's extremely common. We believe that it's something that one in three women will experience during her lifetime. We do see more patients present as they age, after childbirth, and as they approach menopause, but it's certainly not limited to older adults.

Beyond the medical diagnosis, you know, urinary incontinence can significantly affect the patient's quality of life. They may avoid exercise, social activities, travel, or even structured daily routines around it. So, it is something that we are certainly are welcoming the opportunity to address for them.

Host: Right. Yeah, it really can take over your life. There are different types of urinary incontinence. Can you explain the main types and how they differ in everyday life for patients?

Dr. Johnnie Wright, Jr.: Yes. The two most common types of urinary incontinence are going to be stress urinary incontinence, which is leakage of urine with any increase in abdominal pressure. I tell them, coughing, sneezing, laughing, lifting, exercise, anything that increases your belly pressure generates leakage.

The pathophysiology, we believe, has more to do with the waning or decreased urethral support or support to the tube that connects the bladder and the outside world. It's certainly something that we see more commonly in younger patients, and women of childbearing age.

The next most common type of urinary incontinence we see is urge-related incontinence, and it's just how it sounds. Patient gets a strong urge to void and leaks before she has the opportunity to get to the bathroom to urinate. We believe pathophysiology around that is multifactorial. We tend to see more of these symptoms in menopause, so we think that there's some downregulation of hormones/estrogen receptors that kind of predispose them to a little more urgency or frequency. There's also some thoughts around the myelin sheath or the covering of nerves that sometimes contributes to interruption of communication between the bladder and the pontine micturition center or that center in our brain that governs our voiding function.

And then, probably the next most common type of incontinence is a mixed picture, where a patient can have a combination of urge and stress, or in our older patients, we see a little more of what we call functional incontinence, meaning they leak not because that there's something wrong, but just because they don't have the physical ability to get to the bathroom as quickly, and the mobility is typically limited in those patients.

Host: Well, many people assume urinary leakage is just a normal part of aging or childbirth. Is that true? And when should someone seek help?

Dr. Johnnie Wright, Jr.: Of course, urinary leakage is common, but it should not be simply accepted as quote unquote "normal" for us. We tend to see aging and childbirth as risk factors, but not something that automatically commits you to having urinary incontinence down the road, okay? There are many treatments that are super effective, and patients should seek evaluation whenever symptoms become bothersome or they begin affecting their overall quality of life.

For me, it's as simple as explaining to the patients that if your leakage is affecting your quality of life, it is worth having that discussion with the provider so that you kind of understand what's out there. Facts are your friends, and an evaluation does not obligate you to intervention.

Host: Facts are your friends. I love that. What are the most effective non-surgical treatment options available today, and how do you decide which approach is right for each patient?

Dr. Johnnie Wright, Jr.: Yeah. So, I for sure approach it in an individualized kind of fashion. Not every intervention will work for everyone, but I take the patient symptom type, severity, her goals for intervention, and her overall medical history and conditions into consideration. Common non-surgical approaches for management include pelvic floor muscle therapy and/or pelvic floor muscle exercises.

In certain parts of the country, we've got pelvic floor physical therapy, which is a known subspecialty within physical therapy, and those individuals can offer guided therapy for patients with both commonly urge and stress-related incontinence. We also have simple behavioral modification techniques and bladder training exercises. We talk a lot about fluid and caffeine optimization. And then, yes, there are medications for management of urge-related incontinence. There's a whole category of those with some newer agents, you know, truly old school anticholinergics and then some beta agonists with more targeted effect on bladder itself.

And then, we offer most patients, unless there's a contraindication, some vaginal estrogen therapy, because we do know that we see a lot more urge and urge-related symptomatology in patients who have genitourinary symptoms associated with menopause. Many patients experience meaningful improvement without surgery and adopting one or a combination of these non-surgical approaches.

Host: That sounds like a lot of good options. How does urogynecology differ from urology or OB-GYN care when it comes to treating urinary incontinence?

Dr. Johnnie Wright, Jr.: That's a great question. What I would say is the treatment—thank goodness to the board subspecialty and the emphasis on treating urinary incontinence in the subspecialty as a whole—should not differ tremendously. What I will share, though, is a urologist who goes on to do urogynecology fellowship has a little bit different exposure than an obstetrician gynecologist who goes on to do a urogynecology fellowship.

For starters, both do a total of seven years of training, but that split is different. So for a general urology residency, it's about five years with two years of additional training in the fellowship. For general OB-GYN, it's four years of residency and three years of fellowship for that total of seven.

But during those general or formative years, an obstetrician gynecologist is going to focus lot on obstetrics and then on general GYN and gynecologic disorders with some emphasis in just incontinence and management of incontinence. The fellowship itself for both will give you a lot more the nuances of the pathophysiology, the different approaches, and you see a lot of higher level complex patients with multifactorial kind of presentations for their care.

And then, the same thing for urology, they manage general urology presentations and very respectfully manage more of the male population, as opposed to females with GYN disorders.

Host: So for patients who do need procedures or surgery, what advances have been made to improve outcomes and recovery?

Dr. Johnnie Wright, Jr.: I think it's an exciting time in the subspecialty. Probably the biggest contribution and change or surgical intervention that's completely revolutionized how we manage female stress incontinence has been the advent of the midurethral sling. And while we've been doing it for over twenty years, we went from requiring an abdominal incision, six-week recovery to being able to offer treatment that was equally or even more efficacious with a 20-minute outpatient procedure.

 The other advancement, which continues to evolve is, really more so in the management of urge-related incontinence. We now use Intradetrusor Botulinum toxin or Botox therapy, which has been a game-changer. We have been using sacral neuromodulation since 2011 for the management of urge and urge-related incontinence. We've also recently seen implantable posterior tibial nerve kind of stimulators that don't require a patient to come into the office weekly for 12 weeks in a row. So, many of the procedures are outpatient-based, a relatively rapid return to normal activity, which has been super for the patients, super for the providers, and super exciting time overall for just women's health.

Host: That's really encouraging. What advice would you give to someone who's been living with urinary incontinence, but they feel embarrassed or hesitant to bring it up with their provider?

Dr. Johnnie Wright, Jr.: I think it's certainly worth them hearing that urinary incontinence is one of the most common conditions encountered in gynecology and pelvic floor medicine. Patients should truly understand that they're not alone. These conversations are something that should be commonplace or routine for all healthcare providers. And as mentioned before, there's some super exciting options that are out there. And so, simply bringing up the topic should be their first step toward a major improvement in the overall quality of life.

Host: Well, thank you so much for sharing your expertise today. This has been so informative and helpful. We appreciate you.

Dr. Johnnie Wright, Jr.: Great. Thank you for the invitation. Look forward to the next.

Host: Absolutely. Again, that's Dr. Johnny Wright Jr. For more information, please visit prismahealth.org/podcast. And if you found this podcast helpful, please share it on your social channels and check out our entire library of podcasts for topics of interest to you. I'm Maggie McKay. Thank you for listening to Flourish from Prisma Health.