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Stress incontinence and overactive bladder are at the center of this Butts & Guts episode. Dr. Howard Goldman, a urologist in Cleveland Clinic's Glickman Urologic and Kidney Institute, shares the difference between these two conditions, the symptoms that may occur, when to seek medical attention, and more. He also discusses the advancements being made at the Cleveland Clinic to help treat individuals experiencing either condition.

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Stress Incontinence and Overactive Bladder

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio.
And today, we're pleased to have Dr. Howard Goldman, a urologist in Cleveland Clinic's Glickman Urologic and Kidney Institute. We're going to talk a little bit about stress incontinence and having an overactive bladder. Howard, welcome to Butts & Guts.

Dr. Howard Goldman: Thank you for having me.

Dr. Scott Steele: So for all the listeners out there who are regular time, we like to first go into it hearing a little bit about you. So tell us where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Howard Goldman: Thanks. So I'm from Los Angeles, California. Trained all over the country, New York, Memphis, Cleveland, a few other places. Was happy to end up in Cleveland, Ohio. I do a lot of what's called female urology and pelvic floor dysfunction. And so, we do a lot of surgery on things like pelvic floor prolapse, stress incontinence, treat patients with overactive bladder, and other sorts of bladder disorders.

Dr. Scott Steele: So I'm going to start off with a couple of facts that I think I surely didn't know and I think a lot of our listeners may not know. So, one in three people who are assigned female at birth experience some type of incontinence and loss of pelvic support. It's less common in men, but it still does happen.
So on this episode, we're going to be discussing the two most common types of incontinence. That's stress urinary incontinence and urge incontinence, also known as an overactive bladder. So, let's go high level first, let's go 50,000 foot view. Tell us about these two and what's the difference between the two.

Dr. Howard Goldman: So, yeah, and it's actually more than one in three women. It's closer to about 40%-plus. Stress incontinence is leakage with cough, sneeze, exercise, when you're walking your dog and the dog is pulling really hard, or young women tell me when they're yelling at their kids, they sometimes have some leakage. So it's essentially the inability of the urethral channel to provide adequate resistance when the pressure in the belly goes up. So that's stress incontinence. And the general treatments for that are anything from Kegel exercises to we have certain things we can inject into the lining of the water channel to provide more resistance. And then there are surgeries that can help with that.

Overactive bladder, urge incontinence is one component of overactive bladder. Some other things that frequently go along with that are just urgency where people have to run to the bathroom. They may still make it. Whereas, with urge incontinence, they got to run to the bathroom and don't make it. Many of those people also have urinary frequency, go to the bathroom quite often and often will get up at night. And there are a number of different things that can cause that. There are some neurologic things. Patients with neurologic disease may have that. But the majority of patients don't have any obvious underlying causes, and it's just a dysfunction between how the brain and the bladder are communicating, such that instead of having control over the bladder, they lose that control.

Dr. Scott Steele: So you talked a little bit about causes for incontinence, but can you talk about risk factors? How do I know, am I prone to this, or just all of a sudden I wake up one day and I sneeze and boom, I urinate my bed?

Dr. Howard Goldman: So you yourself, as a male, would not be prone to stress incontinence. Really the only men who have that trouble are men who have had some kind of prostate surgery. So often after prostate cancer surgery or some other type of prostate surgery, men may experience stress incontinence. In women, it's very common after women go through childbearing years because as they go through labor and delivery, there can be some damage to the muscles in the pelvic floor surrounding the vagina. There can be damage to some of the nerves in that area. And that, along with sometimes aging, going through menopause, having perhaps had some other type of pelvic surgery, all of those things can add up and ultimately lead to somebody having stress incontinence.
Urge incontinence, really, anybody could get that. We see that in men sometimes who have blockage from their prostate, where the bladder has to work too hard, and it gets jumpy and they develop overactive bladder. And we see it quite often in women for no apparent reason.

Dr. Scott Steele: You threw out some statistics earlier, and just based on what you just said, maybe everybody out there to a certain degree experiences one or another of these, and certainly they don't talk about it a whole lot. So if I'm a listener at home, how do you know when you're supposed to seek treatment for this, and that what you are experiencing is, quote unquote, “abnormal?”

Dr. Howard Goldman: That's a very good question. And these are not problems that are going to kill anybody. These are really lifestyle issues. So, there are many women, I would even venture to say most women who've had vaginal deliveries have some degree of stress incontinence. But for many of them, it may be when they have a hard cough, a few drops come out, and it doesn't really bother them particularly.

But if it gets to the point that it bothers someone, that's when they should seek treatment. And that's all relative. I have older women who maybe wear two pads a day. That doesn't bother them at all. And I have younger women who have just a few drops of leakage, but when they're in their kickboxing course and they get a few drops on their leotard, that is very stressful to them. So it's really, it's up to the individual. If it bothers you, it's not normal. And if it bothers you, then seek treatment.

Dr. Scott Steele: So truth or myth? Incontinence may be improved with lifestyle modifications.

Dr. Howard Goldman: True. So, there are certain dietary things, things like caffeine, alcohol, that can irritate the bladder and make people have to run to the bathroom more often and sometimes not make it.

Weight loss. For patients who are significantly overweight, it has clearly been shown that weight loss can help both stress and urge incontinence. And there a number of other lifestyle changes that can help, as well.

Dr. Scott Steele: So can we talk a little bit about two things? First of all, I'm a patient. I've said, "Okay, listen, I've been fighting this too long. I got to go in and get it evaluated." What can a typical patient expect when they come to see you or a member of your team here at the Cleveland Clinic? And then, what are some of the treatment options that are available outside of the lifestyle modifications that you just talked about that can help improve these symptoms?

Dr. Howard Goldman: So, typically, one can make the diagnosis of these problems with just a very good history, physical examination, and urinalysis. That's often all that is necessary to then move on to potential discussion of treatments. Sometimes, in certain situations, we may need to do further bladder testing, something perhaps called like a urodynamics test, which allows us to understand better how the bladder is functioning. Sometimes there may be reasons to look in the bladder and do what's called a cystoscopy.

When you do then get onto treatment, I would break stress incontinence and overactive bladder, urge incontinence, to separate buckets. For stress incontinence, pelvic floor physiotherapy, Kegel exercises can be helpful for some patients. There are some vaginal inserts which can obstruct the urethra and prevent leakage in some patients. There are some things we do in the office where we just numb up the urethra and inject a gel under the lining to provide better resistance. And then there are surgical options where, in the OR, typically under deep sedation, there's a 30-minute procedure that can provide added support to the urethra to prevent leakage. That's for women with stress incontinence.

For men with significant stress incontinence, they can also do the Kegels. But if that doesn't do the job, and these are again men who've usually had prostate surgery, typically then it would be some sort of surgical management with some sort of either a sling or we make a new sphincter, an artificial sphincter that we implant around the urethra.
For overactive bladder, first-line treatments are pelvic floor physiotherapy, again, and medications. And if those don't work, we then have a lot of other options, everything from injecting Botox into the bladder, and then we do that in the office. We also can do some stimulation of one of the nerves near the ankle, whereby stimulating that on a routine basis, that actually feeds up into the nerves that control the bladder and can help the bladder a lot.

And then we also have pacemakers for the bladder, where we can implant a little pacemaker where there's a wire that goes to the nerves near the bladder. And that's very successful in patients who have failed other approaches.

Dr. Scott Steele: Now, I just want to make sure I heard you correctly. You stimulate the ankle and that improves the bladder? Is that the old “dip the hand in the hot water and you urinate” trick you're talking about, Howard?

Dr. Howard Goldman: You must have gone to sleep away camp, I guess. It's similar except it's the ankle. So it's actually based on some old acupuncture techniques. And if you stimulate the tibial nerve, the tibial nerve actually runs up and becomes part of the sciatic nerve, which then goes up to some of the sacral nerve roots. And those are the same nerves that then control the bladder. So that by stimulating the tibial nerve, there's very good evidence that you can actually help control the bladder.
And a big area of research, we've been on some of the studies, and there aren't any devices yet available. But soon there will be some little, very small implants that you could put under the skin in the ankle that will stimulate that nerve on a regular basis so patients don't have to come in and out to get that treatment.

Dr. Scott Steele: Oh, that's fantastic. So one of the things that I like being here at the Cleveland Clinic, there's always some new innovative treatments going on. So can you tell us a little bit about that, what's happening here at the Cleveland Clinic for bladder disorders?

Dr. Howard Goldman: Yeah, we have a lot of different things we're working on. We have something that's really the only thing in the world being looked at right now for help with diagnosis. I had mentioned earlier that we sometimes will need to do what's called urodynamics to evaluate how the bladder is actually functioning as a test to help determine what's going on. The challenge with that is, a patient comes into a room, you stick a bunch of tubes up into their bladder, you fill them with water, and then you tell them to urinate. And it's a very artificial setting. The bladder doesn't always work in its typical way under that sort of circumstance.
So we actually have, together with our bioengineering people, come up with a device that is called the uromonitor. Once it gets into commercial production it'll probably be called something else. But it's a very small little device. Looks like just a little small curl of rubber that's actually put into the bladder through the water channel. And then we can leave it there for 24 hours. And so the patient can actually walk around, they can go home. They can do all their normal things, let the bladder fill its normal, natural way. Urinate in their own bathroom at home. And while that's all going on, all the information about what's going on in the bladder is sent wirelessly to something that looks like a cell phone that they're wearing. And the next day, they can come in, we have a little string on this thing, we pull it out, and we can download all the information. And we look at it as like a Holter monitor for the bladder. We can essentially figure out what the bladder did for a full day, and hopefully get a much more accurate sense of what's going on. So that's from a diagnostic standpoint.

From a treatment standpoint, we've been very involved in some of the latest research on some of these little stimulators that are placed in the ankle to help overactive bladder. And we're also involved in a study for stress incontinence where we're using stem cells. Patients come in, we do a little needle biopsy of a muscle in their thigh. We then send that little tiny piece of muscle, it's smaller than a match stick, out. And they separate the stem cells and grow all sorts of new muscle cells that we then, three months later, can inject into the urethra, the water channel, to hopefully reform the patient's, or strengthen the patient's urethral sphincter. And hopefully that will help with stress incontinence. So there are a lot of new things we're looking at.

Dr. Scott Steele: So as you said, there's a lot of different treatment options there. How do you help a patient decide what is the best treatment option for them?

Dr. Howard Goldman: So we generally start simple and then move up the ladder to get more complex. And some of it also depends on, there may be some patients who really want to stay away from the operating room and prefer to do things in the office. And there may be other patients who say, "Listen, I just want to do one thing, get this done with, never think about it again." So we discuss it with the patients, discuss risks, benefits, and come to a decision after all the information is laid out.

Dr. Scott Steele: Oh, that's fantastic stuff. So now it's time to get to know you a little bit better with our quick hitter. So first of all, what's your favorite sport?

Dr. Howard Goldman: Baseball.

Dr. Scott Steele: Now, is that to play or to watch?

Dr. Howard Goldman: Well, at my age, it's to watch.

Dr. Scott Steele: Fantastic. What is your favorite meal?

Dr. Howard Goldman: Steak.

Dr. Scott Steele: And if you have a place on your bucket list that you're dying to go to, what is that place?

Dr. Howard Goldman: Ooh, I've been to a lot of places. It would be St. Petersburg in peaceful times.

Dr. Scott Steele: Fantastic. And finally, you said you were an LA guy to begin with. So, what is it that you like about here in Northeast Ohio?

Dr. Howard Goldman: I spent a lot of time in New York, a lot of time in Los Angeles. I'm used to fighting traffic, taking forever to get somewhere. And it's nice to have greenery in front of me, drive peacefully to work, not get caught in traffic. If you leave work at 6:30, generally you're home by 7:00. And a nice medical center, nice people to work with. It's all good.

Dr. Scott Steele: Amen to all of that. So what's the final take home message for our listeners?

Dr. Howard Goldman: I think the take home message would be, incontinence, whether it's stress incontinence, overactive bladder, urge incontinence, is very common. It's much more prevalent and common in women than in men, but it does happen in men as well. And again, in general, it's not going to kill you. But if it does get to a point where it bothers someone, there are some excellent treatments.

And all different types of treatments, wherever somebody wants to go, however invasive they want to be, there are different treatments. And they really should follow up with one of us here at the Cleveland Clinic so we could tell them more about these things and hopefully take care of them.

Dr. Scott Steele: That's fantastic advice. And so, for more information on Cleveland Clinic Glickman Urological and Kidney Institute, please call (216) 444-5600. That's (216) 444-5600. You can also visit the website at clevelandclinic.org/incontinence to download an incontinence treatment guide. That's clevelandlinic.org/incontinence. Dr. Goldman, thanks so much for joining us here on Butts & Guts.

Dr. Howard Goldman: Thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.

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Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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