Maggie McKay (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm your host, Maggie McKay. Today, we're going to discuss female urinary incontinence with Dr. Briana Walton, Director of Female Pelvic Medicine and Reconstructive Surgery and Director of Robotic Surgery at University of Maryland, Capital Region Health and Adjunct Associate Professor at the University of Maryland School of Medicine. Thank you so much for being here.

Briana Walton, MD: Thank you, Maggie. It's a pleasure to be here with you today.

Host: So, let's just start with many women think bladder leaks are just a part of aging. How do you respond to that misconception?

Briana Walton, MD: That's pretty common for women to think, but the truth is it's absolutely not a part of normal aging. That's kind of ancient history. I wish we would just retire that thought. Leaking is thought to be normal. And my mom, your mom, probably, they'll say, "It's just inevitable." But aging is inevitable. Leaking is an option, right? So, we really try to tell patients we've got a lot of highly effective evidence-based medicine treatments, so we shouldn't accept the status quo.

Host: And how does urinary incontinence affect a woman's quality of life beyond the physical symptoms? And why is it important to address openly?

Briana Walton, MD: That's a really important question, because it can be-- if we allow it -- absolutely devastating for a woman because it's not just a physical, it becomes a social and a psychological. When patients tell me that they've stopped exercising, when they say they avoid sexual activities, or they pull away from a lot of their social functions because they're afraid they might smell or they might have an accident, I tell them that's a problem. They stop living greater and they started contracting their lives. And so, that steals really autonomy and confidence. And that's one of the things, I think, actually is associated with premature aging when we take away our ability to do and participate in the kind of lifestyle that we want to. So quite frankly, we try to fix the bladder. We don't just stop with the leak. We try to get people back to their normal function.

Host: That makes sense. What are the main types of urinary incontinence and how do you help patients understand the difference?

Briana Walton, MD: Yeah, I like to joke and say there are a couple of different flavors. You can really think of it in really two easy ways. One is a cough form and one is that "I can't wait." So, the cough form being a stress incontinence pattern where patients basically are saying, "When I laugh, when I cough, when I sneeze, when I jump..." they have leakage associated with it. So, any increase in intraabdominal pressure. And so, you kind of think of it almost like a gatekeeper where the muscles and the tissues have gotten a little bit lazy. And too much pressure on the gate allows urinary leakage to occur.

This is in contrast to urge incontinence, that "I got to go. I can't wait," and it's often referred to as overactive bladder. So when your brain and your bladder have a communication problem, the bladder says, "Go now. Go now. You got to go." And sometimes, there's not much warning associated with it. And this is really more associated with, instead of like a gatekeeper, it's the muscle itself having overactivity, not weakness, but a spasm to it. And it is important for us to differentiate the two, because the treatment options are very different.

Host: At what point should women consider seeing a urogynecologist rather than just managing symptoms on their own?

Briana Walton, MD: You know, it's kind of funny because urogynecology is still relatively new, right? But the moment that I think that you are influenced by your pattern of urinary leakage is the moment you need to start asking questions from a urogynecologist. And even if we meet a patient and decide, "At this point, we don't need to do anything. Your symptoms are mild," it's still important to put a timestamp on it. But when patients start having issues where they're changing their clothes or they wear certain colors so that they don't show leakage and/or if they've migrated from a very small pad to a much larger pad, I think these are signals for a woman to basically pull the trigger and say, "Hey, I need a consultation."

Host: What medical or minimally invasive treatments are available beyond physical therapy?

Briana Walton, MD: Yeah. That's also a good question because everyone usually thinks that I'm just going to say surgery, but we really have a massive toolkit now, and it is beyond your mom's old fashioned, "Hey, do Kegels." We do have physical therapists that we partner with to help improve the pelvic floor strength. But beyond that, we have medications and these are really for that can't-wait type of incontinence or urge to help to calm the bladder down for women who have overly sensitive bladders.

And what surprises a lot of women is that we have something called genitourinary symptoms of menopause. So, menopause is very common in the population that I serve. And actually, just adding back a little bit of estrogen in the vagina itself can cut down on the rates of urgency, frequency, and nighttime urination. Kind of a non-negotiable for us, we really try to utilize this tool as a means to correct a lot of women who have menopause-associated leakage.

And then, I would say the third is probably more esoteric. Most people don't really know about neuromodulation. So, neuromodulation is basically a fancy way of saying we're going to place either a tiny little pacemaker within the spine or near the spine in order to sort of reboot those nerves and help improve that brain to bladder communication. The other option is to utilize botox, which also acts as a neuromodulator. So instead of acting on the muscle side, you're getting the medication to act on the nerve side.

Host: Botox just keeps on giving, right? It's good for a lot of things.

Briana Walton, MD: It keeps on giving.

Host: So when you do need surgical options for women with severe incontinence, what are they and how effective are they?

Briana Walton, MD: That's also a good question because we really undertreat patients. Surgery is really highly effective. Most of the studies out there say they're somewhere between 85-95% successful for that cougher leakage pattern or stress incontinence to utilize something called a sling or a mid-urethral sling. It is just a small piece of mesh material placed underneath the urethra, kind of like a hammock. And it acts like a yield or a stop sign. So when coughing occurs, it increases the pressure so that leakage doesn't occur, but it doesn't obstruct your ability to empty your bladder. And so, the success rates are somewhere between 85-95% for women either feeling like they've gotten much better, or to cure them. I love this as an option because it is minimally invasive. People can go home the same day after the procedure, and really they can get back to their lifestyle activities fairly quickly.

On the other side of it, we talked a little bit about neuromodulation, which I would also consider a procedure or not as invasive as a true surgery, because you're not necessarily making a large incision, but it is a minimally invasive option, both on the botox side and with the pacemakers.

Host: What advances in technology or treatments are making a difference for patients today?

Briana Walton, MD: The main sort of technology that we utilize to try to help us make accurate, real time understanding of what is the bladder saying and what is the urethral function is doing, urodynamics, and it's a fancy way for me. I usually use the analogy of if you're having heart symptoms, we're going to do an EKG. If you're having bladder symptoms, we're going to do urodynamics, because we want to understand how big is a bladder, how much does it hold, how stable is it? What are the triggers that actually cause it to leak? These are important, because they can sometimes help us guide what way we're going to perform the surgery and/or what we're going to offer you for surgical. I have been sometimes using urodynamics, and then said, "Oh, I need to change my plan based on what that study shows."

The other is to really think about more office-based procedures. So, botox is not necessarily done in the operating room. We can do it right here in the office. So, very little downtime. We have really great ways to numb everything. So, the injections are not that uncomfortable. And you can go home right away. Usually, most of those patients will say, "Hey, for six or eight months, I'm doing really great." That's a big deal without having to use medications.

And then, finally, some of the neuromodulation treatments are starting to be brought into the office. So, we've got, like I said, a lot of things in our toolbox that we can start to pull out so the patients don't have to go in one direction in order to treat their incontinence.

Host: Well, what is one piece of advice that you give women who feel embarrassed about seeking help? Because I think a lot of people don't get help because of that very thing, they're just too embarrassed to say it.

Briana Walton, MD: Yeah, I think you're right. I guess I would say that you're not alone. Your doctor's heard it all. I've heard it all before or worse. And the statistics for incontinence are incredibly compelling, because it's such a common problem. For us, as a urogynecologist, we are fascinated, and our pride is tied to actually helping women getting better. We want them better not to judge them. So, I usually say, "Take a deep breath. Put your big girl panties on and talk to your doctor," because we want you to get back to your normal quality of life.

Host: Thank you so much for sharing your expertise, because it affects a lot of women, and it's been very helpful and informative. We appreciate it.

Briana Walton, MD: I am happy to be here. Thank you.

Host: Again, that's Dr. Briana Walton. Find more shows just like this one at umms.org/podcast and on YouTube. Thank you for listening to Live Greater, a health and wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.