Caitlin Whyte (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice. A common misconception is that urologists only treat men. But actually, urologists specialize in treating both men and women, and all genders. Joining us to talk more about women's urologic health and incontinence is urologist, Dr. Curran Emeruwa.

Welcome to Be Well, the podcast from Skagit Regional Health. I'm your host, Caitlin Whyte.

Well, my first question for you today Doctor, is what are the most common symptoms for women experiencing incontinence?

Curran J. Emeruwa, MD: Right, so, just to introduce myself. I'm a urologist. I specialize in female urology and women's health. You might be surprised to hear that urologists, we all know they treat men, but they also treat women too. I'm passionate about empowering women about knowledge about their health, and I'm hoping to help them regain control over their lives, especially when it comes to their bladder. That it is a topic that affects millions of women worldwide, but it often stays in the shadows, urinary incontinence and overactive bladder, because it's kind of an embarrassing issue to talk about. But if you've ever felt embarrassed or alone because of these issues, please know that you're not alone, and there are effective treatments available.

So, to answer your question in terms of what are the most common symptoms for women experiencing incontinence; well, first of all, as I mentioned, it's way more common than many women realize. It affects about one in three women at some point in their lives, so that is a pretty significant number. Yet it's often rarely talked about openly, as I mentioned. Symptoms can really depend on the type. There are really two broad types of incontinence. There's what we call stress urinary incontinence and urge urinary incontinence.

Stress incontinence can involve leakage during activities that put pressure on the bladder. That includes things like coughing, sneezing, laughing, exercising or even lifting something heavy. So imagine you are trying to go to a dance class or go on a hike or playing with your kids or grandkids and then you leak a little bit of urine. That can be incredibly frustrating. And so that's what we call stress incontinence.

The other type of incontinence is what we call urge incontinence. This is often associated with what we call overactive bladder or OAB. Some women have overactive bladder without incontinence. Other women have overactive bladder with urge urinary incontinence, but this is characterized by a more sudden, intense urge to urinate followed by involuntary leakage. So think about when you might be driving home and thinking about going to the bathroom and you feel like you're not going to make it in time or even you're in the kitchen and water's running you think about urinating and you're not going to make it to the bathroom on time. Sometimes women, they are urinating more than eight times in 24 hours waking up multiple times at night. These are pretty much the symptoms that have to do with urge incontinence, but to truly understand these symptoms, we use special tools. So in the office or before patients get to the office, we'll use tools such as the Bladder Symptom Questionnaire, that's what we call the BSQ, and these are just simple surveys to help us evaluate objectively, you know, how severe is the urgency? What type of activities are we leaking? What kind of pads are we using? Some women just have thin liners for protection. Other women are going through three or four pads a day for protection. In severe cases, even have to wear a Depends or an adult diaper.

And so we also try to gauge the impact on our patient's quality of life. And so we use tools, we discuss these issues during the clinic visit, but it's really a spectrum or a wide range of symptoms that our women can experience when it comes to incontinence.

Caitlin Whyte (Host): Gotcha. Alright, well, thank you so much for breaking that down for us at the beginning of the episode here. Now, you mentioned that there is, of course, a stigma that a lot of women have to get over just to even kind of admit to ourselves that maybe we're going through this, but when should women seek treatment from a urologist for these symptoms? When are they more concerning?

Curran J. Emeruwa, MD: Yeah, great question. So really just if the urinary symptoms are interfering with your daily life, even in minor ways, that's when it's time to seek help. So for instance, you might even just notice a small amount of leakage when you go for a hike or go to a dance or fitness class, you go to the gym, you're laughing with friends out for dinner one night, you know, you're lifting the groceries, you're playing with your kids. So even minor incontinence issues like these can be effectively treated. Many women, they're going to feel embarrassed or they just feel like it's a normal part of aging or just something that they have to deal with, but it really doesn't have to be. Really only half of women, that's what our latest guidelines say, that's the AUA, the American Urological Association. They mentioned that only half of women experiencing urinary incontinence actually seek medical help. And so reach out, and that's taking a proactive step towards improving your quality of life, even if the incontinence is, is just mild and there's no need for embarrassment. I think all urologists, all providers within the urology office, all the nurses, even the reception staff. We've dedicated our careers to helping women just like you that are experiencing these issues.

Caitlin Whyte (Host): I love it. Well, what are some of the latest advancements in treating that overactive bladder and urinary incontinence, and how do they compare to the more traditional methods we've seen already?

Curran J. Emeruwa, MD: I'm glad you asked. So, we've had so many significant advancements, that offer new hope for these issues. And it really spans a whole spectrum from minimally invasive or conservative measures all the way to nerve stimulation. So, just to give a broad overview, for us in the urology clinic here at Skagit Regional Health, we do a holistic view.

So we're going to look at your overall health, your diet, your weight and your medications to see if any of those are, have an interplay with your bladder. But then we also offer behavioral therapies such as bladder training and pelvic floor exercises, physical therapy. So we've all heard of Kegel exercises, for instance, and just making sure that we're doing those properly as that can be very effective for some women.

We discuss medications. There's been brand-new pharmaceuticals now on the market. For example, what we call beta 3 agonists. Examples of these medications are Mirabegron and Vibegron. These help to relax the bladder muscle, and this reduces urgency and frequency with few side effects.

And then there's minimally invasive options. There are urethral slings, these are minimally invasive surgical options for stress incontinence with high success rates; about 80 to 90 percent of women experience symptomatic improvement. There's a Bulkamid injection. Think of this as a hydrogel that gets injected into the urethral wall. This enhances its closure during activities. This helps about 80 percent of women. And then as I mentioned, sacral neuromodulation. So these are devices such as InterStim and Axonix. These act like pacemakers, except for the instead of the heart, they're like pacemakers for the bladder. They send gentle electrical pulses to normalize the bladder function and reduce urgency. These can reduce urgency episodes by at least 50 percent in about 70 percent of patients. And finally, there's Botox. Everyone's heard of Botox for the face. Well, it's not just for wrinkles. We can also inject it into the bladder muscle directly, and this can significantly decrease incontinence episodes for about 80 percent of women, with effects that last for anywhere from four to six months.

These advanced treatments are offered targeted relief, and they're personalized for you, depending on the quality of your life, the severity of your symptoms and what other medical comorbidities you may have. We can often find a treatment that is tailored for you.

Caitlin Whyte (Host): Now you touched on this a bit already, but can you really explain the differences between the treatment options and how each one is used in treating different types of urinary incontinence?

Curran J. Emeruwa, MD: It's tailored to the type and severity of incontinence. So as I mentioned before, the stress incontinence, that's going to be better targeted with things like pelvic floor strengthening, physical therapy, because this will strengthen the muscles supporting the bladder that reduces leakage. Urethral slings, as well, provides physical support to the urethra, great for stress incontinence. And finally, Bulkamid, that's the hydrogel injection. This enhances that urethral closure with a minimally invasive injection that takes about 10 minutes. Again, that is great for stress incontinence.

For the overactive bladder and urge incontinence, this is where lifestyle modification comes into play. We look at your diet, we look at caffeine, alcohol intake, medications and managing fluid intake. That's where medications come into play as well, such as the beta 3 agonists that I mentioned that relax the bladder.

This is also sacral neuromodulation specialty where we regulate those bladder nerve signals to help control the bladder. It's like having a remote control for your bladder. And then the Botox injections as well, if we're not looking for something as permanent as an Interstim or an Axonics, the Botox injection is a great way of reducing those involuntary bladder contractions without a permanent device. And so, it's important to note that I take a personalized and holistic approach.

We have to consider all the factors, diet, weight, stress levels, medical conditions, medications, all these things might contribute to your symptoms. And so, again, the treatment pathway and our decision making will depend on the treatment plan that's uniquely suited to you.

Caitlin Whyte (Host): Wow, that customized approach is really, really interesting. Thank you for sharing that breakdown with us. Now, when it comes to these minimally invasive procedures, what should a patient expect during and after them?

Curran J. Emeruwa, MD: Yeah, so not without going into too many details, just a brief overview; with urethral slings, it's a quick procedure under anesthesia. We're talking about 30 to 45 minutes, after we go home the same day. Recovery is about a few weeks with minimal discomfort.

For the Bulkamid procedure, this is about a 10 minute outpatient procedure. We can do it under a sedation with local anesthesia. So you're not under a full general anesthesia. Afterwards, we're resuming normal activities within about 24 hours with immediate improvement in leakage, pretty much noted across the board.

With sacral neuromodulation, it's a two phase. So there's a test phase where we put in a temporary wire for about two weeks to assess the effectiveness of the permanent implant. If it is effective, then we go back to the operating room. We place the permanent implant. This is again, a small device that is implanted in the back. Both of these procedures take about 20 to 30 minutes. And then afterwards we might have some mild discomfort in the surgical area. Usually just requiring some over the counter pain medications and then regular follow-ups just to adjust the settings of the device to make sure that it is effective. There is a battery that comes with the InterStim device, but it does last for about seven years and it's very quick to exchange.

With the Botox injections, think of it like going to the med spa. You come into the office for a quick procedure with my nurse. She places a numbing agent in the urethra. We go into the bladder with a camera under this local anesthetic, takes about 10 to 15 minutes and we do micro injections of the Botox around the bladder muscle. Again, afterwards we do monitor for urinary retention. That's to make sure that you're actually able to pee, but we see symptom improvements within about two weeks and it lasts for again about six months.

Finally, with medications, these are medications that we take once a day. We typically notice improvements within a few weeks with minimal side effects, but again, everyone's going to be a little bit different in terms of how they might respond to medications and pharmaceuticals aren't a great option for everybody, but they are an option that's available.

So throughout any treatment, we have a huge team here that are eager to help. And so if there's any questions or we're needing, you know, wanting to stay informed or supported, my nursing staff is incredible and we're just a phone call away. We also utilize the Epic MyChart system for people that are tech savvy or prefer email or chat.

So, we get back to patients typically the same day with any issues.

Caitlin Whyte (Host): Great. Well, with so many options available to our patients, how do you determine which procedure is the best option for a particular patient?

Curran J. Emeruwa, MD: When it comes down to choosing the right treatment options, we have to do a comprehensive evaluation. We will discuss your symptoms in detail, often using the BSQ, as I previously mentioned, that's that bladder survey, to quantify the impact of your symptoms. We'll try to identify underlying factors. We'll look at your diet, your weight, your stress levels, other health conditions and medications that you're currently taking. We do diagnostic testing and so we're going to test for urinalysis to look for infection or other issues within the bladder. We also may or may not perform what's called a voiding diary or a Bladder Diary, which is some homework that we send you home with; a sheet to complete just to give us a better idea of your urgencies and leakage symptoms at home. We also tailor the treatment options to your personal preferences. For example, you know, what comfort levels or lifestyle; that's going to be crucial in decision making and in terms of what type of treatment options we may discuss.

And finally, it's really a shared decision making process. So we collaborate with the patient to choose the best path forward. By considering all these aspects, we're going to ensure that the treatment plan aligns with your unique needs. We also do have state of the art advanced testing in our office now.

For example, the urodynamics is a special test. Think of it like an EKG for the heart or an EEG for the brain, except it's tailored for the bladder. And so this is a special study of the bladder to help us get a good idea of exactly what's going on. We also may do camera tests, or imaging tests such as ultrasounds to get a better idea of exactly what's going on with the bladder before tailoring your treatment decisions.

Caitlin Whyte (Host): Well, another big question here, but what are the success rates and then also potential risks for these procedures for urinary incontinence?

Curran J. Emeruwa, MD: Every treatment option is going to have different, what we call risks and benefits. And for that reason, we're always going to discuss these and discuss the alternatives. So just generally speaking, here's what you can expect with some of those treatment options that I mentioned before.

With urethral slings, we're seeing success rates. And what I'm quoting are some of the latest data from our national guidelines, from the American Urological Association. So these are really broad based national studies that they compile and, and they publish these data typically at least on a five year basis.

And with the experts in the field weighing in on the interpretation of the data. But the success rates are about 80 to 90 percent for slings. So we do see significant symptomatic improvement when it comes to stress incontinence. The risks that are involved with urethral slings are going to be urinary tract infections, temporary difficulty with urinating or issues when it comes to the synthetic mesh in terms of erosion or pain or even it being placed too tight and then later on needing to be loosened or cut. And so we have seen those issues in the past and it's something to consider when deciding on that option.

For the Bulkamid procedure, that's the hydrogel that goes within the urethral wall; the success rates are about 80%. And that's again for stress incontinence. The risks are again, whenever we're doing any kind of scope procedure in the bladder is going to be urinary tract infection, but it's a very minimally risk procedure and maybe some mild discomfort or burning with urination for a day or two. If it's not effective enough, the need for additional injections, that just means going back in to do an additional injection if we don't get the symptomatic improvement we're looking for.

When it comes to sacral neuromodulation, we see success rates about 70%, with substantial symptom reduction. So that's a greater than 50 percent improvement. The risks of that with any implant are going to be device malfunction or device failure, infection of the device, or pain around the insertion site, either of the lead or with the battery. So something always to consider when we're talking about implants, but otherwise it's a pretty quick procedure and it's low risk. It's done percutaneously. That means that it's done without any incision. We're actually just using a special needle under X-ray guidance in order to place the lead. And so it's a very minimally invasive procedure.

When we talk about Botox injections, we see success rates about 70 to 80%. The risks, again, we're concerned about infection whenever we're introducing that camera into the bladder to do the procedure. But oftentimes with Botox, we are worried about it working too well. And in the fact that it quiets the bladder so much that we lead to temporary urinary retention. In that case, we have to end up placing a catheter for a short time until the Botox wears off a little bit. We don't see that too often. We're often using lower doses of the Botox to start out before increasing, and we do bladder scans or ultrasounds to make sure that we're not retaining urine, but it is something to be aware of when it comes to that.

When it comes to medications, again, the efficacy and success rate really depends on the patient and their medical comorbidities and the severity of their symptoms. But we do see significant improvements when it comes to medication usage. The potential side effects that we worry about, especially for beta 3 agonists, could be changes in blood pressure, mild headache, but otherwise they're generally well tolerated. We see some symptoms such as dry mouth, for instance, which aren't particularly bothersome. And so certainly there's a lot more detail when it comes to this, but these are just some of the potential risks. Again, it's nothing that's too severe or major to worry about choosing some of these treatment options.

However, something to be aware of, of course, when it comes to any treatment decisions, and it's always important to make an informed decision. That is that we understand these options before choosing them.

Caitlin Whyte (Host): Of course, of course. Well, my last question here today, Doctor, how do these treatments improve the quality of life for women suffering from urinary incontinence or other bladder issues?

Curran J. Emeruwa, MD: So, think of these treatment options as transformative. So, first, just regaining confidence, not having to even think about your bladder or fear having leakage during your everyday activities. That is really, I think, the key point. Emotional well-being. So, now we're going to have reduced stress and anxiety that's related to this incontinence issue.

Improved social engagement. Now, we have the first freedom to participate in social events, travel, and hobbies that we love. Better, sleep as well. A lot of patients are having issues overnight when it comes to overactive bladder, and so think about fewer nighttime bathroom trips. This improves rest and energy levels throughout the day.

And finally, just a holistic health approach. So, we address all the underlying factors because sometimes it's like our bladder issues are secondary to something else in our life that's like diet related or stress related. And so actually we end up addressing those issues and we get an improvement elsewhere in our life, and then our bladder improves as a side effect of that.

And so, again, it's incredibly rewarding to see my patients reclaim their lives and do all the things they love without having to worry about it.

Caitlin Whyte (Host): Some really great information here today, Doctor. Thank you so much for sharing. For more information, go to SkagitRegionalHealth.org. And thanks for listening to Be Well, the podcast from Skagit Regional Health. If you found this conversation helpful, please be sure to tell a friend and subscribe rate and review this podcast on your favorite podcast app. I'm Caitlin Whyte.