Online Health Chat with Sandip Vasavada, MD
July 17, 2017
Millions of women suffer from incontinence. Urinary incontinence can be a tough topic to bring up in the doctor’s office, but if you’re constantly leaking or consistently needing to rush to the bathroom, getting help might be easier than you think.
There are two main types of incontinence that cause accidental urine leakage for women, stress incontinence and urge incontinence. Stress incontinence is the involuntary leakage of urine when there is effort or exertion such as sneezing or coughing. Urge incontinence is the strong, sudden need to urinate because of bladder spasms or contractions. Both types can be treated with physical therapy, medications and in some cases, surgery.
During this private, live web chat, Sandip Vasavada, MD will answer your questions about female incontinence and what the options are for treatment. Dr. Vasavada serves as the urologic director in the Center for Female Urology and Reconstructive Pelvic Surgery within the Glickman Urological Institute at Cleveland Clinic. He is board certified in urology-female pelvic medicine and reconstructive surgery. Dr. Vasavada's main clinical interests lie in the area of urinary incontinence, pelvic organ prolapse and complex reconstruction of the lower urinary tract, and management of complications of vaginal and lower urinary tract surgery.
About the Speaker
Sandip Vasavada, MD earned his medical degree from Northeastern Ohio Universities College of Medicine in 1991. He had previously completed his undergraduate studies at the University of Akron in 1987. He completed his residency at Cleveland Clinic in 1997. Subsequently, he began a fellowship in female urology, neuro-urology and reconstruction at the UCLA School of Medicine in Los Angeles. He then took a position as assistant professor of urology at Thomas Jefferson Medical College in Philadelphia prior to returning to Cleveland in 2001.
Let’s Chat About Urinary Incontinence Issues in Women
Moderator: Welcome to our chat, "Incontinence: Leaking or Running to the Bathroom? We Can Help," with Dr. Sandip Vasavada, urologic director, Center for female Urology and Reconstructive Pelvic Surgery at Cleveland Clinic.
Dr. Vasavada, thank you for taking the time to be with us to share your thoughts about urinary incontinence issues in women.
chatter23: I've had to combine problems with urgency with a history of kidney stones. I'm supposed to drink a lot more water than I can possibly tolerate. Oxybutynin has so many side effects, and it didn't make any difference in terms of my ability to tolerate large amounts of water. If I drink even half the amount I'm supposed to, I can't even leave the house. I realize there probably aren't any other options, but I thought I would ask. Thanks.
Sandip_Vasavada,_MD: Yours is a tough situation. I recommend having your doctor consider other, "third-line therapies" for overactive bladder such as BOTOX, sacral neuromodulation or tibial nerve stimulation to help.
KPAL: I have had pelvic floor therapy that did not fix my issue. My local urologist is suggesting InterStim placement. Do you recommend that over trying BOTOX injections?
Sandip_Vasavada,_MD: There are risks and benefits with each approach. BOTOX carries a small risk of emptying problems, but is usually an office-based procedure. The InterStim (sacral neuromodulation) has no risk of emptying problems (it treats it), but is usually done in the operating room at some point. That may be a concern to some patients despite the procedure being minimally invasive and outpatient.
MC123123: If you have a side effect of BOTOX with which your bladder becomes paralyzed, how long does that usually last before the paralysis subsides?
Sandip_Vasavada,_MD: The data on retention problems vary and can be from a few weeks to up to six months. However, in most cases, it is probably a shorter duration; but again, this varies based on the dose used (shorter duration is with lower doses).
tv7: I am a 77-year-old man with problems of frequency, urgency, leaking, etc. How do I know if these problems come from an enlarged prostate or an overactive bladder? Thanks.
Sandip_Vasavada,_MD: That is a great question! You can try empiric, "just try-and-see-what-happens" therapy, which may involve overactive bladder medications. This is assuming you are emptying your bladder well. If this works, you can continue to see if the medication you are taking is well-tolerated.
bifa: I am an 80-year-old male with BPH, and I take 1 bisoprolol/HCTZ 10MG/6.25MG tab daily. Often, in less than an hour after urinating, I have frequent urges to urinate again with a weak stream and little to no output from the bladder. What are best medications to reduce urgent frequency and to increase urine flow to empty the bladder? Also, I wake up to urinate four to five times at night.
Sandip_Vasavada,_MD: I would see a urologist to determine if this is from prostate- or bladder-related causes or both.
MC123123: I have transverse myelitis. I suffer from both urge and stress incontinence due to my neurogenic bladder. Taking Detrol seems to help a little. I was told BOTOX can sometimes paralyze the bladder. What are the chances of this happening?
Sandip_Vasavada,_MD: Yes, BOTOX in the bladder may affect emptying. This is dose-related in that the higher the dose, the more likely it may happen. (The range is 5 percent to 30 percent, including neurogenic patients.) In some cases, even if it does affect the bladder and you can self-catheterize, the outcomes and satisfaction with BOTOX is quite high.
LaFina: Thank you for this opportunity. I take Lasix 20 mg for heart failure. I have a BMI of 21 and am 61 years of age. I have had two pregnancies with normal deliveries and also multiple heart surgeries requiring me to have a catheter for some length of time afterward. I am guessing all of these "attributes" are contributing to my stress incontinence problem (sneezing, coughing or waiting too long). Outside of the usual, "Do Kegel exercises," can you suggest any other non-surgical remedies?
Sandip_Vasavada,_MD: Some patients use the Impressa tampon (found over-the-counter) at major drug stores. At your age, I would have someone evaluate the vaginal estrogen status, as many women find it painful to insert a "tampon." If so, then a short course of vaginal estrogen and/or lubricant can help get the tampon into place easier. This may work for you. If it does, then consider using this versus surgery as the next step. Also, an "incontinence pessary" or ring can be fit in some doctors’ offices, and this may help as well.
Betsysbest: What is your opinion of using Impressa to help control incontinence? I used the product once, and it worked wonderfully for me, but when I removed it at the end of the time period, it scraped the sides of my vagina and was very painful. It even drew a small amount of blood. My doctor told me I am extremely dry, and I am now using Estrace twice a week. I haven't tried Impressa again since I started Estrace. I am afraid of damaging my vagina, but would like to use it since it worked so well the first time. Do you have any opinion on this product? I will be seeing my doctor again this summer, but wondered if you have had any experience with it?
Sandip_Vasavada,_MD: Impressa is a good product, but your concerns are understandable. I would retry it after a six- to eight-week time period on the estrogen cream. If it gets too cumbersome or expensive to use (as many patients say), then you can consider physical therapy and/or surgery (usually a quick, outpatient surgery) to help.
All of a Sudden
CAB: I am a woman, age 30. During the past several months, I have had extreme urges to urinate, and often the urges come on very suddenly. Sometimes, when I then go, it does not seem like I had a full enough bladder to warrant such a strong urge. Also, sometimes urine will come out at random times. For example, some came out while getting out of my car the other morning after just using the restroom. It can be very disruptive, like when I am out shopping, for example, all of a sudden I have to use the restroom and I have to go NOW. I have had fibroids in the past, which were removed (going on three years). I am a little worried they might be coming back, as I have been spotting. My question is: What do you think could be wrong, and/or can you please share some tips for physical therapy or ways to control this? Thank you.
Sandip_Vasavada,_MD: This is not an uncommon scenario of overactive bladder. Minding caffeine and fluid intake can help. Physical therapy with a pelvic floor PT specialist can help as well. They may teach Kegel pelvic floor exercises or "quick flick" quick contractions of the pelvic floor, which can aid when you are in a tough situation such as a grocery store line. After that, medications and then third-line therapies such as BOTOX, sacral neuromodulation or tibial nerve stimulation will be beneficial. There is hope.
crl: In the past year or so, I have been in a store shopping and suddenly my bladder will just start emptying and I cannot stop it. I am 64 and otherwise very healthy, although I am probably around 30 pounds overweight. This has happened twice, and it is absolutely horrible as you can imagine. I don't drink alcohol and only one or two cups of coffee a day in the morning. Both times this has happened, it was early evening. I have had stress incontinence for approximately 10 years. What might be going on?
Sandip_Vasavada,_MD: It could be overactive bladder, but in many cases, in combination with the stress incontinence (we then call it mixed incontinence). A specialist can determine which direction is most likely to help you most.
FLOSEY: I have been told I have a prolapsed rectum, as well as bladder drop. For years I’ve had trouble with IBS. I have been told that because I had a hysterectomy 25 years ago and also had radiation, it has thinned my walls to lift my bladder. I have an appointment with Marie Fidela Faralso at Cleveland Clinic. I am wondering if I should have made an appointment with a urologist instead, or will she be able to help me? My appointment is August 18.
Sandip_Vasavada,_MD: You are in good hands with her, and she can address the urologic issues with you as well.
BJ42: What causes prolapsed bladder? Is it only in women who have given birth?
Sandip_Vasavada,_MD: There are many causes, and vaginal childbirth is one of the more common in addition to prior pelvic surgery, weight gain, weak tissues from excess straining and a genetic predisposition.
Tweety: Can you discuss the use of hormones to help strengthen the vaginal wall and urethra in the hopes of preventing prolapse or incontinence?
Sandip_Vasavada,_MD: This is a very controversial subject, despite the fact many specialists use it, because it is not well-studied. Even for treatment of incontinence and/or prolapse in the situation of atrophy (lack of estrogen), the treatment is not firm, although again, many of us use this approach.
Mulling Over Medications
goldfish: I am taking one 10 mg tablet of oxybutynin ER at bedtime. This results in a heavy flow at night, but light flow during the day. Is there any way I could balance the flow between night and day, i.e., maybe split the dose, 5 mg in the morning and 5 mg at bedtime?
Sandip_Vasavada,_MD: Sure. That product is available in 5mg strength and can be prescribed accordingly, or the immediate release format (5mg IR) can be used the same way, twice a day.
EMG: About 15 years ago, I became urge incontinent. My doctor at the time tried two different drugs, which worked for about a year each. I now use pads 24/7. I am 75 years old with Stage 3 kidney disease. Have there been any additional drugs developed? I do not have access to the names of the drugs I used.
Sandip_Vasavada,_MD: There have been several drugs developed during the last 15 years, but they all work about the same. I would avoid trospium for you, as it is metabolized through the kidneys compared to all of the others medications that go through the liver.
june: What is your opinion about the use of Ditropan? Will it get less effective when frequently used?
Sandip_Vasavada,_MD: It should not get less effective, but sometimes the bladder situation can get worse; hence, the medication no longer works as well. We usually revisit the amount of caffeine and stimulants being consumed, as these substances will render the medications less effective.
goldfish: I would like to re-phrase my original question. Would splitting the 10 mg dose of oxybutynin correct the problem of heavy night time flow versus light day time flow?
Sandip_Vasavada,_MD: Usually this medication (10 mg ER pill) cannot be split. If your problem is night time urination or production of urine (in excess), you should see your family doctor, as it is usually a body fluid issue more than a bladder issue.
Something About Surgery
turtlelady: Is it better to wait as long as possible before having surgery for prolapse or does it not make a difference?
Sandip_Vasavada,_MD: Most of us who treat prolapse do so based on patient bother. If you are not bothered by it, we can usually wait. There are a few factors that may make someone consider treatment early on, but this does not come up often. Your health also is a factor, and although we cannot forecast how your health will be in several years, we can get a general idea.
Marge: What is involved with a sling procedure? How long does it take? How long do I need to take off from work? How long would a sling last? Does it ever need to be replaced?
Sandip_Vasavada,_MD: Sling surgery is quite effective, and if using a synthetic mesh tape, can be done as an outpatient in most cases. It takes about 30 minutes or so. I usually recommend taking a week off of work and avoiding heavy lifting for several weeks. Typically, the mesh will not move after several weeks and is otherwise permanent, although it may not last forever, as our tissues and muscles change as we age. This may cause leakage again, but we’re not really sure if this is due to a sling "not lasting" as opposed to our bodies really changing. If you use your own tissue for a sling (autologous fascia), the healing phase is much longer.
GRAMMYRUTH: I have another question about the sling. What is its success rate?
Sandip_Vasavada,_MD: Sling success varies depending on the definition of success. That said, most patients (upwards of 85 percent) are satisfied, with most using minimal pads if at all and having rare leakage.
CAB: Do you recommend that I schedule an appointment to discuss overactive bladder? Should it be with a urologist or my general doctor (Lauren Fuller, MD)? Thank you for your help.
Sandip_Vasavada,_MD: You can see either physician. A general doctor can initiate therapy, and if simpler things do not work, a urologist/pelvic health specialist can certainly take it from there.
simplyasking: How do you know if you are doing a Kegel exercise the right way?
Sandip_Vasavada,_MD: You should be not contracting your abdominal muscles in the course of the Kegel or pelvic floor exercises. I could recommend several videos on YouTube that can guide you through this.
carole: Please discuss caffeine use and stimulants.
Sandip_Vasavada,_MD: Caffeine is a strong stimulant for the bladder and causes urgency and frequency. It also may cause or exacerbate leakage. Other stimulants include spicy or citrus products and artificial sweeteners (especially in excess).
That is all the time we have for questions today. Thank you, Dr. Vasavada, for taking time to educate us about urinary incontinence in women.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.
To make an appointment with Sandip Vasavada, MD or any of the other female urology specialists in Cleveland Clinic’s Glickman Urological & Kidney Institute, please call 216.444.5600, toll-free at 800.223.2273 (extension 45600) or visit us at clevelandclinic.org/urology for more information.
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