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Dr. Warner Huh (Host): Hello, this is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama, Birmingham, UAB. And I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh. Today, we're going to discuss an important prevalent issue in women's health, specifically urinary incontinence.

And with me today is Dr. Susan Meyer, who is an Assistant Professor in the Division of Female Pelvic Medicine and Reconstructive Surgery in the Department of Obstetrics and Gynecolgy here at UAB. Welcome Dr. Meyer.

Isuzu Meyer, MD (Guest): Thank you for having me today.

Host: Well, I think this is an incredibly important topic, mainly because I think it's under-recognized and maybe it's something that women don't like talking about, but we're going to talk about urinary incontinence and I thought maybe you could just tell us you know what the definition of urinary incontinence is, the prevalence, risk factors, what women need to know, and our listeners need to know.

Dr. Meyer: Definitely. Thank you again. Urinary incontinence is a very prevalent condition, as you mentioned. As with any chronic condition, the prevalence increases with age, and if you're in your twenties and thirties, maybe one in 20, 1 in 10 or five to 10% of women with have a urinary incontinence, but, you know, as you age, by age 80, more than 50% of women, or at least every other women in the United States have some sort of urinary incontinence and some studies report even higher prevalence, like 60 to 80% in these women, older women have this condition.

And some of the risk factors, you know, in addition to aging and menopause that I mentioned, are childbirth and obesity. People with no childbirth or no history of vaginal birth, they are not risk-free. But if you have childbirth or vaginal deliveries, their risk of incontinence increases. And when I mentioned the prevalence or how common urinary incontinence is in women, it is surprising to many people how common it is, but the reported prevalence is thought to be underestimated or under reported. So, what I mean by that is it's actually more common than you think. And the reason is women with urinary leakage or urinary incontinence, they don't report their symptoms. You know, they don't talk about it. It's not a sexy topic to talk about.

So, they don't talk about it. Because they don't talk about it or report their symptoms, they're not counted or included in epidemeologic studies. So, many women with urinary incontinence actually suffer in silence. And I wanted to talk to you about why that might be. The studies have shown that the more than 50% of women, they don't seek care and they don't talk about it. And the reasons are many reasons, but these women are embarrassed to have urinary incontinence. You know, like I said, these women, it's not something that they talk about at the dinner table. They don't talk about it when they get together with friends. And another reason is that they assume that it is actually normal part of aging which it is not, but they often say, you know, my mother and my grandma, they all had this problem when they got older. So, they think, they assume that this is just normal part of aging. And lastly, they believe that there's nothing that can be done, which is not true, but that's the reality.

So, I believe practicing medicine as you know, Warner, it's is a privilege. And I have heard many times, my patients say, you know, I have not even told my best friend or my partner or my spouse or my husband, but yet they are telling how bothered they are to a complete stranger, which is me. And, you know, as a provider and about how devastated they are about this problem.

And so my passion is to be an advocate for women's health and improve their quality of life. And I'm grateful that I'm able to help these ladies and I'm making a difference at an individual level. But the same time, you know, I know I have more work to do to educate the community and to increase awareness and it is not normal part of aging.

And there's something that we can do to help. And patients tell me, you know, I wish I had done this sooner, or why did I wait so long after the treatment? And this is actually also quite common, more than 50% do not seek care for this person. Every other women, they have this problem. They are not talking about it.

For those who actually seek care, on average, they live with this condition five to 10 years before they seek care. So, it is a big problem. So I'm actively involved in national professional society, American Urogynecologic Society, along with my partners, Dr. Richter, who is currently the President of the OGS, the society who, which focuses to improve care for women with pelvic floor disorders, such as incontinence or pelvic organ prolapse, which is described as you know, dropped bladder, a bulge in the vagina and trying to increase awareness of this burdensome condition.

And we are trying to promote research in this area. We've collaborating with the NIH and different institutes within the NIH, and also having discussions with the Congress in DC, ultimately to increase research and hopefully improve awareness and hopefully broaden the insurance coverage for this treatment, the treatment for these conditions.

Host: And this is the exact reason why I thought this is an appropriate topic for you and I to discuss. One is just the sheer prevalence and the fact that at the bare minimum, we're talking about one in two women that actually suffer from urinary continence in their lifetime, but you used the word normal and the normal part of aging. And I agree with you. I mean, I think that a lot of women stuff from this, but I would far from consider it being normal. And I think it's just something that is woefully sort of under-recognized and I think women just accept it for what it is. I think the quality of life consequences on women is enormous, but the best part is that we actually have treatments that actually can improve their continence if not totally reverse it. And you know, again, as a consequence, improve their quality of life. So, I thought maybe you can just talk to us a little bit about what are those treatment options. Perhaps the surgical and non-surgical treatment options for urinary incontinence.

Dr. Meyer: Definitely. So, before I get into the treatment options, I want to talk about the types of incontinence or types of leakages because the mechanism is different and therefore the treatment is different. So, there are two most common types of incontinence in women. And one is called stress leakage. So, which is, we at the ladies cough, sneeze and leak, you know, often they talk about, oh, I had to cross my legs before I cough or I leak urine. And the other one is jumping and lifting, you know, jogging and they start leaking.

So, these ladies actually alternate their lifestyle. They used to enjoy running and jogging and no longer able to do that. And so that is a stress urinary incontinence. The other most common type of leakage is urgency incontinence, which is often associated with strong urinary urgency, cannot suppress the urge to urinate and starts to leak urine.

So, mostly known as gotta go, gotta go. Can't make to the bathroom and starts to leak. And so, and as I mentioned, the mechanism is different. So the, the treatment that we offer is different and we have to first figure out what exactly is going on and what type of leakage these women have. So, I often see first thing first, you know, the most the more you drink, the more your urine your body produces.

So, I often see women complaining of urinary frequency and, you know, they always say they got to go, got to go, and they're always going to the bathroom. And I ask about fluid intake and how much they are drinking and it actually, it's not uncommon that these ladies say, well, I'm trying to drink a gallon of water, trying to lose weight.

And I stopped my morning with coffee and energy drinks. You know, so the recommended daily intake, fluid intake a day is about 60 to 80 ounces or six to eight glasses of water or fluid. So, definitely these ladies nearly double the daily recommended intake that they're drinking. And on top of that, caffeine is a diuretic. So, it promotes urine production. And also not many people know this, the caffeine not only is a diuretic but also bladder irritant. So bladder will squeeze, spasm to get rid of urine. Just like when you eat something nasty, you want to spit it out. The bladder goes through the same thing if they have a caffeine in the bladder, in the urine in the bladder, bladder will spasm squeeze as hard as it can to try to get rid of the irritants. And so we often start with fluid management. Pay attention to not only how much, but what you drink and also do not wait until the last minute. We call it proactive toileting, to make sure you can get to the restroom in timely manner. And behavioral management and pelvic floor exercises are quite helpful, but beyond that, for urgency urinary incontinence, we have several treatment options.

So, normally the bladders should be completely quiet while it's being filled and acts as a reservoir. And when it reaches near capacity, the bladder will let you know that, by giving you a signal, starts to spasm, and that's the sense of urgency and by increasing bladder pressure you know, you know when you need to use the restroom?

In women with urgency urinary incontinence though, the bladder pressure increases regardless of bladder volume. So, bladder spasms frequently, and sometimes the pressure is so strong that you cannot suppress the urge and it starts to leak. So, treatment for that is how we can reduce the bladder spasm or the pressure generated by the bladder. After conservative treatment, often offer oral medications. There are two types of, or two classes of medication. And actually the efficacy is similar between the two different groups or the different classes. So, we choose solely based on the patient's other medical co-morbidities, medical conditions, medications, and also side effect profile.

And then unfortunately also the insurance coverage. And beyond that, we have what's considered third line treatment options. The goal is how we can reduce the bladder spasm of squeezing. So, the bladder squeezing is controlled by the nerves and bladder muscles and the nerves send signals to the bladder muscles and the muscle squeezes.

So, we can either target the nerves responsible for the bladder spasm or the muscle directly. And the one that targets the nerves is called sacral neuromodulation. In a nutshell by placing a lead where the bladder nerves are located and to send the correct signals to the bladder so the bladder receives proper signals and behaves as it should.

And the other option, other target is of course the muscles directly. So, that's when we inject Botox to the bladder muscles. And it is not cosmetic Botox. And this is similar to when you have eyelid spasms, so twitches and you inject Botox to the eyelids and you can still open and close the eye normally, but eliminate unwanted excessive spasms.

So, when you inject Botox to the bladder, you can still squeeze the bladder and empty as you normally would, but it reduces the unwanted spasming of the bladder. So, those are the urinary incontinence treatment specifically for urgency.

And now moving onto, I would like to address treatments for stress leakage and stress leakage on the other hand is more of a structural and support problem under the urethra and bladder. And the urethra and the bladder, the part of the bladder should be supported. And when you lose still those support for whatever reason, the urethra is unstable and starts to leak. So, that's what the most common type of stress leakage, the unstable urethra.

So, the goal is to put the support back in under the urethra. And there are two approaches and conservatively, we can put a medical insert or device called pessary, which is a silicon made device on silicon made insert. And as long as you wear this, your bladder is supported and reduce leakage, and it requires fitting in the clinic.

But it's designed so that you do not have to remove to urinate or have bowel movements. And of course the gold standard is the surgical procedure approach is called midurethral sling. It's a small graft placed under the urethra and there is unfortunately, no regenerative medicine in this area. So once the support structure's gone, there's little tissue in the area that we can use to put together or plicate.

So, by placing the small synthetic graft, it acts as a scaffold for your own tissue to grow and to rebuild the structure they used to have to create the support so you do not leak urine. So, those are some of the main treatments that we offer.

Dr. Warner Huh (Host): So, in summary, you know, for the listeners, there are really two main categories of incontinence. One is urge incontinence, like you talked about as well as stress incontinence and the treatments are uniquely different for the two. And again, I'm assuming that some patients actually have a little bit of both urge. So, I think that there's, there's a whole cadre of really both nonsurgical and surgical treatment options for women that have incontinence.

So, you know, one of the things that has been discussed both in the scientific literature and as the lay press, Dr. Meyer, is this concern of using mesh materials, particularly in the vagina, whether it's supporting the midurethra or elsewhere, I thought maybe you could just briefly dive into what the concerns are.

Is that something that, you know, patients should be concerned about if they have surgery and maybeto provide some guidance there.

Dr. Meyer: Definitely. I'm glad you brought it up. So, midurethral sling is considered actually a gold standard for treatment of stress type leakage, and not only in the United States, but also across, you know, the worldwide and because of this recent FDA announcement on transvaginal mesh products, that was actually the products, mesh products indicated for prolapse, or vaginal prolapse placed vaginally. Because of this announcement there has been a lot of confusion on midurethral slings. FDA makes a clear distinction though, between the transvaginal mesh for prolapse and the midurethral slings. And since the nineties, when it was first introduced to the United States, the midurethral sling has been the most studied anti incontinence procedure in medical history, and they're considered safe and effective even recognized by the FDA. Surprisingly, over 2000 publications, including long-term followup studies have been published. You know, a few years ago, a couple of years ago. So, the number continues to rise. And when you talk about risks and risk categories, classes by the FDA standard, the sling is still placed in class two category, which is the same as for instance, like pregnancy test kit or wheelchair and things like that.

So, they understand the risks of this misurethral sling but they also consider it as a safe material. And the sling material is called polypropylene, which is stable and safe material, used not only in gynecology, but also used in other surgical procedures, including cardiovascular, transplant orthopedics, ophthalmology, ENT, urology, and general surgeries to name a few.

So, it's a very safe product. And thanks to this advancement in medicine and science, we are able to offer this minimally invasive procedure for the treatment of stress urinary incontinence, where before this, I'm sure you remember. this, but we had to harvest the graft from patient's abdominal wall, make five inch incision through the abdominal wall and through the abdomen, just like the Cessarian section to get a strip of tissue so we can put it in the vagina and compared to this, the midurethral sling, not only it is more effective and durable; it is significantly less morbid. It's a 15, 20 minute procedure, fewer complications and patients recover much faster. So, that is one of the things that I wanted to bring up today.

Host: Yeah. I mean, this is exactly why I'm asking the question because I don't want patients and our listeners to be confused about the issue of mesh in the vagina. I think that's distinctly separate from the devices that are used for midurethral support as you're describing and, you know, having done many of the earlier generation procedures to correct stress urinary incontinence. I mean, I, I can just tell you, and I know that you agree that these mid urethral slings are transformative, not only in terms of reducing the risk of complications, but in terms of really adequately addressing their stress urinary incontinence, it's been like the gold standard of care for, for several many, many years now.

Right. And you know that there's no zero risk or risk-free procedure, but when compared to other procedures available, definitely midurethral sling is considered a gold standard for the treatment of stress urinary incontinance.

No. I mean, I think there are a lot of lives have been transformed by these procedures and it's a good thing. So, so let me ask you, I mean, so why, why should women consider coming to UAB for their urinary incontinence care? I thought maybe you can comment briefly.

Dr. Meyer: Definitely. So, out urogynecology clinic provides evidence-based comprehensive care for women with pelvic floor issues, such as urinary incontinence, as I mentioned today, as well as bowel leakage and pelvic organ prolapse or bulging in the vagina. Our providers are a true advocate for women's health, not only making a difference at the individual level, helping one by one, but also through research to advance science and are the leaders in the field of female pelvic medicine.

And we were involved in many, many trials, including midurethral slings and other procedures to advance science. And all of us are very importantly, all of us are fully board certified surgeons with extra subspecialty training to provide care, safe and effective care for women with incontinence and prolapse. And so we are proud of our true multidisciplinary clinic.

In addition to our providers, our clinic has been recognized as the first center, nationally, the center of excellence by the national association of full continence. We're working together with our urology, colorectal surgery, geriatrics and radiology colleagues. We work together to provide excellence of care. So we hope to continue to help women with these burdensome conditions so that we, that they no longer have to suffer in silence from these conditions.

Host: Yeah, I totally agree. And I, I want to make sure our listeners understand the degree and the level of expertise that the providers in your clinics provide, because it's really remarkable. And like I mentioned earlier, you know, the medical and surgical procedures that you offer to women have been truly transformative. It's just remarkable. So, it's really strong work to you and to your division. I don't know if you have any other thoughts or closing comments that you wanted to make to our listeners today Dr. Meyer?

Dr. Meyer: No, we are here to help and you know, we are always open and, we are all dedicated to help women with this burdensome condition. So, thank you for having me today.

Host: Thank you, Dr. Meyer, for all that you do. So again, I'd like to thank Dr. Meyer for her time and sharing her expertise in the area of urinary incontinence. And as always, please rate this podcast and we welcome any comments, particularly on topics that you're at all interested in. And more information on urinary incontinence management and the clinical services that UAB provides, please check out UABmedicine.org. And until next time, thank you. And I hope you all have a great day.