Caitlin Whyte (Host): Welcome to the Health Exchange with Speare Memorial Hospital. I'm Caitlin Whyte. And with me is Dr. Joseph Ebner, an experienced obstetrician and gynecologist from Speare Memorial Hospital. Well, to start us off today, Doctor, can you tell us what is urinary incontinence, and how common is it among women?

Dr. Joseph Ebner: Urinary incontinence is defined as leakage of urine when not intended. What I mean by that is that for all of us, when we became two or three years of age, we gained control over our bladders. And we worked out this relationship with the bladder that, on our time, we tell it when to empty. And between those times, we stay dry. It's extremely common as men and women get older. And today, we're going to be focusing on women. But as we get older, a couple of things can happen, which makes leakage of urine when you're not sitting on the toilet more common.

And for women, there's a couple of different types of urinary incontinence. One is called stress urinary incontinence, and the other is called urge urinary incontinence. Both end up leading to leakage requiring pad use, which is not a problem except that it can be a nuisance, and chronic wet pad use can lead to breakdown on the skin and can cause discomfort and irritation.

And so, the take-home message is that regardless of what type of incontinence you might have, there are lots of treatment options. And so, it's important to bring that to the attention of your healthcare provider and potentially pursue a consultation with a gynecologist to help.

Host: All right. And of course, as you know, there's often stigma or embarrassment surrounding incontinence, even just discussing it. So, what do you say to patients who are hesitant to even bring this up?

Dr. Joseph Ebner: You are absolutely right. There is a stigma and an embarrassment about this, and I think the role of a gynecologist is to make the patient feel comfortable addressing not just this topic, but other gynecologic topics, anything from periods to intercourse, menopause. So, this is in that list of things. And in my experience, most women when they're in a comfortable environment do open up about this. But typically, what I'll ask is: Are you having any problems with your bladder? That's not the first question we ask in an exam. You know, this is well into it, but just open-ended question. Are you having any concerns or problems with your bladder? And if the answer is yes, try to give them that time that it takes to have an open conversation about it. It's never rushed. And really, just let them know that it's a very common concern that women have, and that there's treatment for it. And so, when we put women at ease and talk about the various treatment options, it helps them to open up and have that conversation.

Host: And what are some of the most common causes or contributing factors to incontinence in women?

Dr. Joseph Ebner: Absolutely. So, let's break that down into the two types of incontinence first. I'll talk about overactive bladder or urge incontinence first. Back when we were two or three years old, our brain and our bladder worked out this deal where we got control over our bladder. And for most of our adulthood then, the bladder is supposed to, as it is filling, give the brain a gentle nudge, a gentle reminder that, "Hey, I'm starting to fill up. And if you could take a break in what you're doing, I could be emptied." And so, we've all had that experience for most of our lives, right? Like you're reading a book or you're watching a movie or you're at work and you know you have to pause your activity, and you are able to stand up and leisurely walk to the bathroom, sit on the toilet. And then, the brain says to your bladder, "Okay, it's time to empty," and you can go.

Well, there are various things that happen as we get older. And that circuitry gets kind of short circuited. And sometimes this happens because let's say for many, many years, you've been holding your bladder as you're driving home from work or driving home from being out and about. And one of the first things you do when you get home with an urge to go is to go to the bathroom. And so, sometimes when this short circuitry happens, there's a trigger that, as I pull into my driveway or as I'm opening the garage door, as I'm trying to get in the front door, the bladder has a mind of its own all of a sudden. It starts to contract, it starts to empty, even though I'm not quite ready for it. So, there are certain triggers like that that women will say, "Yep, that's how I have a huge urge to go right when I'm getting home." It is probably because for decades, one of the first things we did leisurely was to go to the bathroom when we get home. And so, that urge incontinence, the bladder has this urge to go that, instead of fully filling, it starts to contract down, starts to constrict, and starts to empty before you're sitting on the toilet. Usually then, what symptoms this causes is "I have to go and I have to go now," and you're dropping and you're running to the bathroom and just barely getting there on time, and sometimes you're not getting there on time.

Host: So, what treatment options are available at Speare for women experiencing incontinence?

Dr. Joseph Ebner: Couple of things that we can do, we could do a physical therapy referral. There are a group of physical therapists that have done kind of a residency, extra training in pelvic floor physical therapy and incontinence physical therapy. They are a tremendous asset to the gynecologist when it comes to having the time and the resources to train women about their pelvic floor and to reinforce healthy bladder and bowel habits that can help with urinary incontinence.

When it comes to this urge incontinence that we're talking about, a couple of things that we can try, number one, it seems ironic, but when the urine becomes too concentrated, then it acts as a bladder irritant. And instead of the bladder filling, the bladder wants to constrict and empty. And so, typically, what we'll recommend is you should be drinking enough water throughout the day that your urine is free from strong smell or odor, and it should be clear in color. And if it's becoming concentrated, you need to drink more water. And ironically, when you drink more water, it's not as irritating to the bladder. And for many women, that will allow the bladder to fill and give you that gentle reminder that it's time to go instead of that urge to go. So, one thing we recommend is drinking plenty of water throughout the day.

The other thing that is used often, and we got this from nursing home literature, is something called timed voids. And so, just like if any of you are parents who have trained a toddler on how to go to the bathroom and how to control their bladder, we do the same thing as adults. We set our cell phones, we set our timer throughout the day. Set your timer to empty your bladder every hour. I know you don't need to go that often. But every hour, you're now telling your bladder, "Hey, I'm going to go to the bathroom now on my time, I'm going to empty it." And then, when you can maintain control for a couple of days or a week, you then say, "Well, now set that timer to every two hours." So, you're now reinforcing those neurosynapses, that connection between the brain and the bladder to say, "I'm in control, and I'm going to go every two hours." And when that is controlled for a number of days or weeks, then you extend it to every three hours. And you work with the patient to continue this over a period of time, reinforcing that I'm in control, not the bladder. And that's one way that you can then space out those urgencies.

The other thing we can do with behavior is that for some women, they're able to stay relaxed and calm even though there's this tremendous urge to go to the bathroom. Try not to give into it. This sometimes will cause leakage initially, but if they can just let the bladder relax and not give into it, now they can reward their bladder by getting up and leisurely walking to the bathroom and emptying. And so, for some women, trying to relax and delay through that urgency will help them get better control over it.

If these things, physical therapy and the behavioral modification from how they time their bladder voids and how they increase their fluid, if we can't get optimum control there, there are a handful of medications that can be used that your gynecologist can prescribe, which will help the bladder relax a little bit, give you a little more lead time so that it gives you a little more warning when it has to go, and it cuts down on that urinary urgency. And so, these class of medications, again, there's about a half dozen that are out there are generally well tolerated. And your gynecologist can work with you on those medications to find the one that's right for you. That's a whole discussion that we've just had about urge incontinence.

The other kind of major incontinence is stress incontinence. And stress incontinence is the leakage of urine that occurs in a stressful event such as coughing, laughing, sneezing, jumping up and down, bending over. Anything that increases the pressure in the abdomen could lead to stress incontinence. And how does this happen? Well, there's a couple of risk factors associated, and it's not going to be this way for all women, but some of these risk factors for stress incontinence include menopause, having had a vaginal birth in the past, being overweight and obesity.

Basically, before having children and when women are in their teens and 20s and 30s, the urethra, which is where the urine comes out is tucked under the pubic bone. That pubic bone is that bone at the very bottom of your abdomen that you can kind of feel, that hard bone at the bottom of your abdomen. On the inside of the vagina, just under the pubic bone is where the urethra is prior to having a child. When the child's head comes through the birth canal-- and if you have subsequent children, that doesn't help the situation-- but when the head comes through the birth canal, some of the connective tissue around the urethra that holds it in position gets damaged and stretched. And what that can lead to over time is when you cough and bear down, instead of the urethra sitting just under the pubic bone, it starts to drop a little bit down into the vagina. We call that urethral prolapse. And when the urethra prolapses down into the vagina, well, now when a woman bears down or coughs or sneezes or laughs, the pressure in the bladder is greater than the pressure of the urethra and fluid like urine flows from high pressure to low pressure, and then little bits of urine can come squirting out during those episodes. We call that stress incontinence.

The reason this happens more after menopause, is that where the vagina and the urethra are located, two things. Number one, women spend most of their lives standing up in the upright position. And so, the vagina is now basically a hole, and gravity plays a role here, things can kind of prolapse or drop. The other thing after menopause is that with the lack of estrogen, the loss of estrogen, those estrogen receptors throughout the pelvic floor and throughout the vagina are no longer being stimulated by estrogen. And so, that also leads to a laxity or a loosening of the connective tissue for things to prolapse. So, those are some of the causes of stress incontinence.

The treatment options, there's, again, surgical and non-surgical options. Early in the course of stress incontinence, teaching a woman how to do the Kegel exercises. Kegel exercises are vaginal pelvic floor exercises. These exercises, they're not abdominal muscles, but they're the muscles that a woman would use to stop the flow of urine midstream. They're the muscles that a woman would use to squeeze around a tampon or around a finger in the vagina. And what the muscle exercises do is we train women how to exercise those muscles of the pelvic floor so that when there's a cough or a sneeze coming, that the reflex goes to the pelvic floor and there's the strength there to hold up, the pelvic floor elevates and supports the urethra under the pubic bone where it's supposed to be. So for early stress incontinence or for women who have just had a baby, for example, we will often review Kegel exercises as a way to strengthen the pelvic floor. For some women, they have a hard time identifying those muscles or they're already doing the Kegel exercises and they're not getting full control, this is where physical therapy would be really helpful. I mentioned before about physical therapists who have had extra training in pelvic floor rehabilitation. And their expertise is invaluable to the gynecologist and to the patient in identifying the muscles that are weak and that need strengthened just like you'd strengthen your back muscles if your back was sore, just like you'd strengthen your leg muscles if your legs were not working as well. Pelvic floor physical therapy can help strengthen the pelvic floor muscles to help with stress incontinence.

In women who have tried Kegel exercises and tried physical therapy, there's also something called a pessary. A pessary is most similar to a diaphragm, and it is a soft, rubber, disc-shaped like a diaphragm. It gets placed in the vagina by the patient. And it can help support and hold up that bladder and hold up that urethra during those periods of stress and cough and laughing to help support the urethra under the pubic bone so that there is improvement in the leakage.

Now, for some women, they might only notice stress incontinence when they go for their runs or they go for their exercise or they go play golf or tennis. In that population of women, especially if they're young, 30s, 40s, or 50s, it's a great opportunity to use a pessary because they keep it in their gym bag. As they're getting ready to go out and perform their exercise, they can place it like placing a tampon, place it in the vagina. It'll help provide that support. They can wear it throughout their exercising routine and stay dry. Then, they can take it out, wash it off, soap and water, and keep it in their gym bag.

As women get older, sometimes they lose that dexterity, but they still have stress incontinence and many women in their 70s, 80s, 90s use a pessary, they can no longer because of arthritis or their dexterity, unable to take it in of themselves, then the gynecologist can help that with a visit every three or four months. And then, she wears the pessary, uses it continuously, and that's safe. And the gynecologist can help the patient through that.

In the event that these non-surgical approaches are not leading to desired treatment, there is a minimally invasive outpatient surgical approach that, in an operating room under usually a spinal anesthetic or a light general anesthetic, an incision is made under the urethra. So, it's a vaginal skin incision just under the urethra and through two small holes, one in each groin, a little piece of synthetic mesh can be placed. It kind of looks like a thick shoestring. And that little mesh sits under the urethra in a way that it holds the urethra stable under the pubic bone, and that little piece of mesh stays in place, holds the urethra in place so that when, after the procedure, she bears down coughs or sneezes, the urethra is in the correct anatomic position and that continence is maintained.

This technology, this procedure has been around since the late 1990s. Gynecologists and urologists have been successfully using these sling procedures since that time. We have really good long-term outcomes. Patients can expect at least 20 years or so of improvement and success with the sling procedures. The nice thing is that they are minimally invasive. There's minimal time away from work, minimal time away from activity. And it's an outpatient procedure, so there's no inpatient stay. If a woman thinks that might be for her, I would say speak to your gynecologist, and they can talk more about those risks and benefits of that procedure.

Host: And take us back to the beginning for a second. How do you evaluate and diagnose the different types of incontinence?

Dr. Joseph Ebner: Thank you for that Great question. This evaluation for stress or urge incontinence usually takes a couple of appointments. One of the first things we do at the first appointment is take a detailed history. And sometimes, to be honest, it'd be a little bit confusing. A patient might say, well, I do have urgency, but it's associated when I cough and I sneeze. And so, we kind of have to tease that out. We'll do a detailed examination. That examination will involve a speculum exam looking for other evidence that things have kind of dropped or prolapsed in the vagina. That examination might have a woman even with her bladder a little bit full, bare down and cough, looking for objective signs of leakage. And sometimes we put a small sterile Q-tip in the urethra to help measure how much it has prolapsed or dropped down the vagina with coughing and sneezing. So, we take a good history, a detailed gynecologic exam.

And what I find very helpful is I'll send the patient home with some homework. And what I want them to do for two or three days is to-- and I provide them like a little hat that goes into their toilet to measure all of their voids and their frequency. And so, we know that the bladder in public and the bladder in a gynecologist's office isn't working the same as it does maybe in your home environment. So by sending someone home with some homework for two or three days, they measure the size of their voids and the frequency, and they record it on a graph for us. And then, we review that table with the patient when they come back for a follow-up. And we're looking for characteristics that are more consistent with urgency and frequency and urge incontinence, or we're looking for symptoms that are more consistent with stress incontinence. And for some women, for many women, there's a combination of both. And so, sometimes as part of this evaluation, it's incumbent to ask the woman, "What's the bigger bother for you? What troubles you more?" And if the bigger issue is urgency, and maybe once every couple of weeks, there's some stress incontinence, but daily there's urgency, we usually will try to focus on what's the bigger concern first. And so instead of tackling both at once, we'll take a couple months to tackle one or the other, get things optimally controlled. And then, we can turn our attention to the other type if it's still a problem.

Host: Great. And, doctor, wrap it up for us today. If a listener is experiencing some of the symptoms you mentioned, what's the first step they should take and what can they expect from that first visit?

Dr. Joseph Ebner: I would say the first step to take is to know that urinary incontinence is not a condition that you have to live with the rest of your life, that there are surgical and non-surgical approaches that a gynecologist practice can help with. So, the first step is to feel confident that this is something we deal with every day. We will approach it in a sensitive manner and to give the gynecologist a call and to make an appointment. That first encounter will be a detailed history and physical exam. You can expect to go home with that homework we talked about to see how your bladder's working at home, and usually a follow-up appointment to talk about what was the bigger problem, what did the homework show, and whether we're going to deal with a non-surgical approach or a surgical approach, behavioral therapy, physical therapy, or medication approach. And all of that then is open to discussion. And typically, we'll try one or two things and then see how it goes for a month, come back, try something else.

Plymouth OB/GYN has three gynecologists, all of which are happy to help with female incontinence. So, feel free to give myself or Dr. Elizabeth Disney or Dr. Taylor Augustine a call, and we'd be happy to see you.

Host: Thank you so much, Doctor. That was Dr. Joseph Ebner. For more information, visit spearehospital.com. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Caitlin Whyte. And this is The Health Exchange with Speare Memorial Hospital. Thanks for listening.