Female Bladder Leakage: Solutions to Get Control‎ | Christopher Tarnay, MD | UCLAMDChat

Good morning good afternoon or even good evening depending on where you’re coming from welcome my name is Dr. Christopher Tarnay and I am the chief of uro-gynecology here at UCLA in the department of obstetrics and gynecology and today we’re going to talk about female bladder leakage and we’re going to focus in on solutions solutions how to get control of this very challenging problem for women so during the webinar feel free to ask questions we’ve got cleave over here he’s monitoring our Twitter account you can use the hashtag UCLA MD chat UCLA MD chat or you can just put comments of comments on Facebook and during the webinar we’ll be tracking them and at the end I’ll address some questions all right let me start off from some geography does anyone know where this might be this is the Blue Ridge Mountains and it’s an northern part of Virginia I had the opportunity as a medical student in Georgetown when I was in DC to go and visit them and one thing I didn’t know at the time was that the Blue Ridge Mountains and the vagina share something in common I hope I have your attention now and what they have in common is similar topography women have estrogen and estrogen in the vaginal area creates a thickening and that thickening creates small little buckling of the tissue creating tiny folds called rugae and these rugae are very important to they create a functional impact on the vagina it has rugae to allow lubricants and secretions it also those rugae allows stretch and the rugae are like this peaks and valleys and that stretch allows function during childbirth during intercourse and the problem later on as estrogen decreases either during menopause or estrogen decreases during breastfeeding or after childbirth is that that elasticity goes away the vagina tissues can flatten and those rugae flatten it becomes thinner and dryer and that can lead to challenges during these transition times with inner core also bladder control and that’s what I want to talk with you about today female bladder leakage is urinary incontinence what is urinary incontinence the involuntary leakage of urine or simply put urinating or leaking urine when you don’t want to one of the biggest questions patients have for me when they come into the office is they feel kind of isolated they go is this the only thing happening to me is this urinary incontinence am I the only one who has it and it’s important that you know that it’s extremely common two out of three women have a lifetime risk of suffering from urinary incontinence now although incontinence increases that was one gets older it actually can happen anytime during the life span and women can experience symptoms at any time it affects over 200 million people worldwide and in the United States alone at least 25 million and of those 25 million 9 to 13 million women have either bothersome or severe symptoms how about a few more facts urinary incontinence is under diagnosed it’s under under reported and as I mentioned it increases as we get older it’s primarily a female problem as over two thirds of people who have urinary incontinence are women there was a study looking at random sample of forty five thousand different households and during that survey 35 37 percent of the women reported incontinence just within the last two months in the elderly over 70 percent have complaints of urinary incontinence and this alone can be the reason for elderly individuals to be transitioned to a different living situation to a skilled nursing facility to assisted living just to manage the incontinence this graph shows that as we get older urinary incontinence becomes more common and young women in their 20s and 30s about 30% middle-aged women’s 40s and 50s 40% and in the mid-60s 65 beyond the menopause over half of women will suffer from urinary incontinence another question I hear a awful lot is is it normal to leak a little urine or it’s just a little urine is that that’s normal right no it’s not normal leakage is common but it’s not normal and it’s really important to understand that women who suffer incontinence can do so in a very gradual in an insidious fashion because it’s a gradual and insidious problem so often women don’t think it’s a medical condition and don’t bring it up with their physicians or medical providers this causes delay in women seeking care and it’s very important for us to communicate and you communicate with your friends and for you to know one doesn’t have to live with urinary incontinence without seeking treatment it’s important although urinary incontinence isn’t life-threatening it’s what I call quality of life threatening and it can affect a woman’s life in many different domains physical reducing physical activities because they don’t want to leak psychological they don’t want to they feel like they’re old they’re concerned about the odor they lose their self-esteem higher rates of depression in women with urinary incontinence they reduce their social act interaction one woman said to me I never go anywhere anywhere without being near my boyfriend John I mean she always always near the toilet she felt shackled to it padding undergarment use very costly and problematic some women have will say they pack two suitcases when they travel one for their clothes one for their pads occupational can you know women who are working this can cause a reduction in going to work and avoidance of intimacy all right women with incontinence offer suffer in silence and this is part of the dialogue that we want to change survey of women suggests that women don’t like to talk about this problem even with their provider and candidly doctors aren’t so great at it either we don’t do a great job asking patients about it throughout our four doctors in one survey when after their visits during their annual screening the doctor didn’t even ask them or screen them about issues of incontinence this leads to a delay woman’s will often wait over six years before with living with the condition before they even bring it up we need to change the way we are looking at and incontinence bring it out from the shadows bring it out from the bathroom and start to recognize it times are changing and the the one of the ways and one of the avenues is the pharmaceutical companies the companies that are selling medication medications and treatment are going to direct to consumer marketing this ad was during the Super Bowl last year for a new a new drug you see this in print ads media ads there’s Playtex has gotten in on the action they have a product called impressa that’s designed to help prevent urinary loss it works by inserting in the vagina similar to a tampon to compress the urethra to prevent the leakage we have celebrity endorsements now coming to the front talking openly about female bladder leakage and urinary incontinence and offering ways for women to get control but more importantly this I think is going to help bridge the the big gap so we can start having a conversation so there’s two main types of incontinence stress urinary incontinence or what I would call exertional loss of urine so this isn’t any time losing urine with coughing laughing sneezing or physical activity hey Doc I don’t jump I don’t jump in the trampoline with my daughter anymore because it causes leaks I wanted to play hopscotch I don’t I don’t I can’t do that with my daughter or my kids it’s common after pregnancy particularly pregnancy that results with it with a vaginal delivery so stress incontinence is basically increased pressure on the bladder that overcomes urethral resistance coughing laughing sneezing all can create urinary loss by pressure and a lack of support underneath the urethra the other type of incontinence is urge urinary incontinence or I think this is the symptom when patients say I got to go I got to go I can’t make it to the toilet otherwise termed overactive bladder overactive bladder is to do with women have this overwhelming inability to resist the the sensation to urinate it has to do with early and inappropriate signaling of the bladder normally we should be able to sense our bladder feeling if we’re out and about where I say it not now I’m in the movie theater I’m at the store I’ll wait till I get home overactive bladder is a problem when you’re unable to suppress that sensation and either due to increased sensation or muscle contractility squeezing the bladder involuntarily triggering urinary loss so urinary urgent continence is leaking urine with strong urge it’s also typify by urinary frequency and urgency often women can’t hold their bladder more than two hours at a time they feel like they have to go and they may leak right before they make it to the toilet that’s urinary urgent continence sometimes it causes patients to wake up at night typical normal is about one time but anyone who’s waking up 2 3 4 even 5 times a night to urinate is classic for overactive bladder one problem patients often relay is that dr. right when I get home I pull my car on the driveway where I’m walking up the the walkway to the front door I put my key in the door I got to immediately drop my bags run to the toilet and they when I ask them they go yep that’s me it’s called locking key syndrome so who gets you’re nearing contents women two times more likely than men that sounds awfully unfair why is that anatomy and risk factors quick Anatomy trip we’ll talk a little bit about the physiology the kidneys filter the blood the waste products of that blood filtration ends up in the kidneys and delivering it to the bladder through conduits called the ureters the bladder is a storage organ and it should store urine comfortably and painlessly until you’re ready to urinate and then once you’re ready to urinate was out through a tube called the urethra one of the reasons women are particularly vexed with this problem is physics they have a short urethra very short tube men typically have a longer tube like a urethra increase increased resistance women with a shorter tube less ability to resist and so anything that might cause detrimental detriment to the anatomy can trigger urinary incontinence like vaginal delivery or occupational exposures we’ll talk about those what are the risk factors age as when we get older we talked about estrogen as estrogen recedes the vaginal tissues change leading women susceptible to overactive bladder and stress urinary incontinence what this changes in the bladder lining pregnancy pregnancy itself does something to contribute to bladder weakening if the pregnancy results with a vaginal delivery the more vaginal deliveries higher risk of urinary incontinence medical conditions with chronic repetitive straining coughing asthma chronic constipation smoking can all contribute to unary incontinence activities women with occupational exposures there was a study in Sweden looking at women who worked in nursing homes transferring patients lifting Gurney’s those women when they compared them to age match controls had higher rates of pelvic floor problems including urinary incontinence obesity the more weight you have particularly if it’s over 30 more pressure on the bladder more pressure and stretch to the pelvic floor and genetics some people are just prone and this is a big area of research and trying to understand which women might be at risk this is a slide demonstrating the older you get the more common the problem is I talked a little bit about pregnancy this is a cartoon just to show the impact on the various structures of the pelvic floor during the act of childbirth here’s the bladder here’s the vaginal canal here’s the rectum as the fetal head comes through this space it puts pressure here press pressure on the rectum it can cause disruption of the connective tissue it can cause stretch of the pelvic floor muscles and all of those compression can can injure the bladder and it’s support okay what are the treatments for urinary incontinence and that depends which set of symptoms are most bothersome or most bothersome is it exertional loss of urine is that urgency and frequency and sometimes is it both and then if they have both we try to target which problem is most problematic for the patient so if it’s stress incontinence is an urge incontinence or both types the first best option for all types is pelvic floor muscle exercises conservative non-surgical non-medical therapy it’s the foundation for all therapies a little bit about pelvic floor muscle exercises also known as kegels the pelvic floor extends from the pubic bone all the way back to the tail bone and in between this area you know in a woman this is a side view is the bladder the vagina with the uterus and the rectum and it’s contraction of these muscles that allow the squeezing and the increased pressure around the outlets for these structures like the urethra or the rectum and in this instance we’re trying to contract the pelvic floor to increase resistance for urination contracting the pelvic floor also can actually feed back on the bladder and reduce urgency called urge suppression so as I said pelvic floor muscle exercises are the same thing as kegels something patients get told to do all the time one of the important critical features is that we have to recognize there is good evidence level one controlled trials evaluating pellet or muscle exercises and its impact on urinary incontinence and it works about two-thirds of the time it can be done on your own or with the help of a sub physical therapists physical therapists who actually train especially to take care of women’s health issues they can work with patients teaching them how to do them properly learning tips to identify the correct muscles is critical because when we ask patients just to do kegels without any instruction about two or thirds of the time they’re not able able to do them properly it’s very easy for us to identify if I say go do an arm curl and I want you two to strengthen your biceps muscle it’s very easy to see a biceps curl if I ask you to do a kegel exercise it’s impossible to see or know if you’re doing it properly and so this is where therapists can really help with that biologic feedback the biofeedback to help women learn how to do this proper skill as with anything requires practice and a commitment because if you stop there’s evidence to suggest patients who have initial benefit but then stop doing their kegels or their pelvic floor exercises the incontinence can come back it’s an excellent first option even with the benefits of Kegel exercises in the pelvic for strengthening sometimes over the long haul it’s not quite enough this is where we have to think about other issues like surgery and the good news is there’s lots of good minimally invasive options that we have available to help correct urinary incontinence for the long term and I want to talk about those basically we want we want to be able to have women run jump and sneeze without pain this is I thought these were cool hashtags hashtag mom problems and hashtag underwareness all right so I mentioned slings let’s talk about them for a moment what’s a sling it’s a 20 minute 20 minute outpatient procedure home the same day – correct urinary incontinence it’s been around for over 20 years in its current form small incision surgery it places a support under the urethra to prevent the loss of urine with exertion so this is a video here’s a spore support pressure triggering urinary loss we need to do something to help the support we can use a sling it can be a small piece of material either permanent or your own tissue that we put though provides that backboard and prevents urinary loss highly effective very simple and this is what it looks like it can either be what we call retro pubic and there’s ones that come out what we call trans obturator through the through the groin small little piece one centimeter wide underneath the urethra highly effective and with over with ten with ten years of data over 80 year care improvement rates objectively at two years long-haul seventy seventy year a seventy percent plus what else do we have a laparoscopic surgery called the birch it’s also a same day surgery using small incisions supporting the bladder neck from above no implant no materials bulking volcans kind of like collagen many and we use it as a filler many women are sort of used to seeing celebrities with lip filler it for collagen and the material that we use is a similar type biologic material where we put it right at the bladder neck here is an open bladder neck we put the bulking agent in like like a collagen material and it increases the resistance by co-opting co-opting the urinary outlet really increases the pressure and reduces a urinary loss there’s also some new exciting things at UCLA were involved with research and one of the most exciting areas is looking at essentially what is essentially extend us a stem cell-based therapy we call cell based therapy it’s using muscle cells muscle progenitor cells and we implant them into the urethra to restore function the formal name is autologous muscle derived cells and we’re doing studies ongoing at UCLA right now we take muscle cells from the patient’s thigh we send them to a lab we grow them up in culture after a couple months we bring them back and we do an office-based procedure to implant– them near the urethra to give new finger function for the urethra no surgery no foreign implants it’s your own tissue and no incisions all done in the office very exciting very new getting back to the treatments like I said what are we gonna do is so moving on to urge incontinence pelvic floor exercises excellent first therapy for for women with overactive bladder dietary and fluid fluid modification becomes very critical for these types of patients and we put patients on what we call a bladder diet and it’s sounds a lot worse than it actually is but it means removing triggers that might cause blow-up bladder overactivity and here’s a list of just a few of the ones and what I would call sort of the the common suspects that might contribute to bladder overactivity caffeinated beverages alcoholic beverages carbonated beverages acidic juices can all potentially cause bladder irritation and urgency and frequency spicy foods even chocolate sorry ladies but movie these things from the diet can often give you great insight as to what your bladder triggers are and then you then have control over your bladder and it’s all about giving control back to the patients all right what if kegels don’t work what if that bladder diet doesn’t work what else do we have we’ve got other things medication Botox neuromodulation and posterior tibial nerve stimulation so medications have been around a long time you’ll see them directly marketed to consumers and doctors may have told you about them before but they’re all designed to help reduce the urinary urgency and frequency and the incontinence episodes when we look at them over placebo most all of them have some benefit sometimes it’s mild and the main class are these what we call anticholinergic medicines and here’s a list with their trade names and they all these ones all function in a similar fashion there’s all more recent introduction that’s a what call a beta 3 agonist that acts a little different mechanism and they all work pretty well reducing urgency and frequency and incontinence episodes there’s no free ride there is some side effects the anticholinergics most commonly are dry eyes dry mouth constipation and dizziness and the beta 3 agonist headache joint pain dizziness blurred vision all of them generally mmm mild and not severe but can be very annoying and sometimes the side effects are more problematic than the condition they’re trying to treat so it’s highly individual independent but if it used quite commonly what else do we have well for patients who don’t do well with the pelvic floor exercises who don’t do well on bladder diet and they’re still having difficulty who have tried medicines and it didn’t work or tried medicines and don’t want to take it we have some other options how about Botox well everyone’s familiar with Botox used for cosmetic reasons we can actually use it in the bladder it’s an office procedure we take a cystoscope and we look inside the bladder and we place the Botox at different places within the blood or using a small injection needle and when we look at the results it reduces urinary urgency and improves bladder capacity and about 60% of 60 to 65% of patients the benefit lasts but it’s not permanent so it’s usually only about six months so often patients need one or two treatments a year the side effects are very low but are important discuss because sometimes the Botox does such a good relaxing the bladder muscle that patients have a difficult time emptying completely but that occurs in only about 3 to 6 percent of patients how about other therapies well there’s a there’s a therapy that we’ve been using for over 10 years called neural modulation it involves placing a lead or a little wire right into the nerves above the buttocks it’s for a severe and refractive overactive bladder patients who didn’t do well on medications and it’s kind of like using a bladder pacemaker when we put a little implantable pulse generator just in the back above the buttocks with a little wire that connects through little nerve roots in the sacrum and this reduces urgency and frequency considerably and the real nice thing about it is we can actually evaluate plate patients before do the implant with a temporary evaluation and for women who have successful temporary leads placed when they go on to get the permanent one eighty percent reduction in urinary leakage so that’s very exciting and no medication in its long standing the batteries last up to five to seven years and just would need to be replaced periodically another type of therapy that’s a form of neuromodulation is posterior tibial nerve stimulation it’s an office treatment requires nothing other than a small acupuncture needle placed right at the ankle and we put a little mild electrical stimulation through a little handheld battery pack this little stimulation on the ankle works the nerves that work all the way up to the sacral nerve roots to affect the bladder and reduces urgency it requires a 30-minute session so you come in the office sit down with your clothes on with your book your iPad or your Kindle have a 30-minute session after the acupuncture needle is placed and we do it for 12 weeks and we look at this data it works about as well as medication about as well as medication we’re still not sure about the long-term benefit as often patients need boosters maybe once a month or so but that’s very exciting for women who can’t tolerate medications and don’t want to go through the troubles of other of their therapies so to summarize solutions for control stress incontinence pelvic floor muscle exercises and dietary change if one wants to do surgery we’ve got slings birch bulking all with excellent data overactive bladder pelvic floor exercises Kegel exercises medications Botox normal Asian or that posterior tibial nerve stim okay I think that’s all I have for you but I’d like to answer some questions and I think Cleve may have some for us okay all right the first question is a diet question and then is should I remove all chocolate and alcohol and improve my lifestyle before I decide on surgery I would say it’s always prudent to utilize all conservative therapies before all conservative there are four therapies before we talk about surgery the draconian implementation of removing all chocolate and alcohol is kind of severe but I what I tell patients I say think of it like an allergy avoidance take it out for a few days and see if it makes a difference if caffeine if chocolate if alcohol is a true trigger you will notice a difference in your bladder function with just two or three days of removing it out of your diet and then it’s all about control because if you notice your bladder does better you just if you have to be out that day you just skip your morning latte but if you’re at home and you’re near a toilet no problem alright another question on neuromodulation neuromodulation ten technique what’s the pros and cons is it as effective as mesh alright so that’s a good question I’m going to go back one slide just to differentiate when we talk about neuromodulation it’s for patients with overactive bladder it’s the type of incontinence with urgency and frequency the pros of neuromodulation is it doesn’t require medication it’s a long-term treatment once you get it in and it’s works you’re done you have to think about for five years it just requires some maintenance programming that’s very simple to do and easy to teach and it’s fairly safe complication rates with neuromodulation are very low about 9% of the time patients have to have the implant removed either for it that it’s not working or sometimes it can bother patients because it’s sitting or pushing on the skin in an uncomfortable fashion it’s the question is that is it as effective as mesh we don’t use any type of mesh at all for our slings for overactive bladder that would be for stress incontinence so that would actually be treating two different things I hope that answers your question all right all right when do you know if you have to have a mesh all right so I’m gonna go to that question right now because I actually have a question prepared for you so let’s I’m going to skip that for a sec and we’ll go back to so is the mesh safe and when do you know you have to have it the mesh is safe and it should be utilized for patients who have stress urinary incontinence for slings what you’ve heard and what the FDA has intervened on is use of mesh for prolapse which we haven’t talked about today that’s uh that’s prolapse of the bladder prolapse of the vagina when we apply mesh in those settings it the complication rates are in my opinion unacceptably Tigh and we I do not advocate anyone getting transvaginal mesh for their prolapse however we have great evidence of safety and effects the efficacy for slings and so using mesh for slings I think is a reasonable idea because the safety and effectiveness of slings is well established in clinical trials that followed patients for over a year and since 2008 the FDA has consistently differentiated between transvaginal mesh for prolapse and transvaginal mesh for sui we’ve got good evidence that mesh slings can help stress incontinence not good evidence that it’s safe for patients with transvaginal mesh for prolapse that being said we have non mesh slings as well we can use your own ones own tissue so patients who work who are leery about it and I would definitely advise you to talk to your doctor before you consider anything like this to talk about using your own tissue as well as a viable option this is just all the law as you this is where all the all the patients when they come in they’ve all seen this online and on TV all right if that but on any further questions I think I’ll go to the Kegel question because that generated a lot of interest earlier so I’m gonna swing back here so one one important thing I’d like to leave you with is how do I do a Kegel all right so pelvic floor muscle exercise are only going to help if done properly and there’s many ways to learn and I’ll show you one way and I have a short cartoon this is from big bump TV so typically the best thing to do is to do it when you’re not distracted do it while you’re lying down or seated going back here’s your pelvic floor here’s the rectum the vagina and the the first thing you want to focus on on is the back think as if you’re holding in gas that you don’t want to pass gas the next thing to practice is think as if you want to contract as if you don’t want to pass urine and then do them both together and hold it for 3 5 even 10 seconds once you learn that skill do 15 contractions for 1 set 15 contractions holding it for 5 to 10 seconds relaxing and repeating do 3 sets a day every day that’s a good kegel exercise routine alright I think that’s all we have for now one more question got one more question Cleve has it alright one more question about leakage after urinating which category does that fall into and what’s the best treatment for that alright so the last thing we’ll talk about is what is what this individual is asking about is what we would call post micturition leakage or dribbling many women will feel like they’re empty they’ll stand up and they’ll lose a little bit of urine that is often reflective of incomplete bladder emptying and it may be due to poor poor Anatomy so patients might have you might have a dropped bladder or a dropped urethra which actually contributes to a small amount of urine pooling near the opening that’s not evacuated while you’re seated and then once one stands typically that small amount of urine can leak out and that can be addressed with a more proper evaluation in the office all right thank you for signing on today and I appreciate you questions you