Ladies When Bladder Control Is a Problem with Dr Katie Propst

Podcast Transcript

Nada Youssef: Hi. Thank you for joining us. I'm your host Nada Youssef. If you're a woman that suffers from accidental or involuntary loss of control of your bladder please stay tuned. Women experience incontinence twice as often as men. Pregnancy, childbirth, menopause and the structure of the female urinary tract all account to this. Rightfully so, it could be very difficult to talk about and that's why we're here today. Please send in any questions you may have regarding this subject in the comment section below. For today's topic, we have with us urogynecologist  Dr. Katie Propst. Thank you so much for being here today.

Katie Propst: Thank you for having me.

Nada Youssef: Thank you. If you just want to go ahead and introduce yourself to our viewers.

Katie Propst: Sure. My name is Katie Propst, I'm an urogynecologist here at the Cleveland Clinic. I've been practicing here for about a year. I take care of patients who suffer from prolapse and incontinence and other pelvic floor disorders.

Nada Youssef: Great. What kind of patients would see you versus just a primary care?

Katie Propst: Sure. That's a great question. Often patients will come to me directly but these concerns with incontinence or prolapse are warranted to bring them up to your primary physician or your gynecologist and you can be further referred to me if it's necessary.

Nada Youssef: Great. Thank you. Before we begin, please remember this is for informational purposes only and it's not intended to replace your own physician’s advice. Many people with incontinence, I can imagine, it's difficult to bring that up and a lot of people learn to cope with it or just live with it. So let's kind of start with a very general explanation of what the urinary system is composed of.

Katie Propst: Sure. The urinary system is composed of the kidneys where the urine is made and then the urine travels into the bladder from the ureters, those are tubes carrying urine from the kidneys down into the bladder. Then in the bladder urine is stored until we're ready to empty the bladder where the urine is released to the urethra.

Nada Youssef: And that would be the process of urination then?

Katie Propst: Sure. Typically, our bladders are storing urine most of the time and then when we're ready to urinate, that's when the bladder contracts and the urine is emptied.

Nada Youssef: So when do things go wrong?

Katie Propst: Well, things may go wrong at different times. Generally, when we think about urine leakage, something is going wrong during what we call the storage phase of urine. Because during the storage phase, urine is supposed to remain in the bladder. So during the storage phase, the bladder muscle wall may be overactive causing an urge and leakage with that contraction or the urethra where which carries the urine into the toilet may be weakened and not supported well, and then urine is allowed to leak out with physical activity.

Nada Youssef: Now, when we talk about the pelvic floor, I want to talk a little bit about what is the pelvic floor and what disorders come with it?

Katie Propst:  The pelvic floor is really a set of muscles that cover the opening of the bony pelvis. So those muscles work to support the bladder, the uterus and vagina and the rectum. When things go wrong with those muscles we can have a prolapse, which is basically a herniation or a bulging of the pelvic organs into the vaginal canal or out of the vaginal canal. Urine leakage can occur or bladder control problems and bowel control problems can also occur with pelvic floor problems.

Nada Youssef: Are there symptoms that once we have it, we know that something may be wrong with our pelvic floor?

Katie Propst: Yeah. Patients may complain of urine leakage at inconvenient times, bowel leakage or trouble emptying the bowels or just a sense of a bulge or pressure in the vagina.

Nada Youssef: Is constipation a symptom of this?

Katie Propst:  It can be but not always. I think a physical exam and taking more history from the patient can also often help to sort out those kinds of questions.

Nada Youssef: Sure. Now, when we talk about urinary incontinence, are there different types of urinary incontinence?

Katie Propst:  There are. There are a number of types of urinary incontinence. I would say the most common types in women are stress incontinence and that's leakage of urine with activity or really anything that puts pressure on the bladder. For some women that would be sports and for other women with more severe stress incontinence, that may just be a sneeze or walking. Another type is overactive bladder and urge incontinence, and that's as I mentioned earlier when the bladder wall muscle is overactive and squeezes too often, and that can cause urgency and leakage of urine. These conditions can happen simultaneously. So some patients may have both urge and stress incontinence.

Nada Youssef: With stress incontinence, it kind of sounds to me like if someone went through childbearing or pregnancy or is this also could be before?

Katie Propst: It could happen before but most women who have stress incontinence have had some event that leads to some weakening of the support of the urethra that carries the urine out of the bladder and childbirth is a major risk factor for that.

Nada Youssef: I see. And how is that diagnosed? Just incontinence in general.

Katie Propst: Typically, all types of incontinence begin with taking a history from the patient and understanding when the leakage occurs and how long it's been going on. And understanding how it impacts the quality of life because a lot of these conditions, we treat based on their impact of quality of life. So once we gather a history, a physical examination is the next step and then further testing may be indicated but it depends on that patient situation.

Nada Youssef: So if someone's going through urinary incontinence, do they go straight to a primary care physician or can they go straight to an urogynecologist?

Katie Propst: Well, I think it makes sense to see your primary care physician first. Some patients do present directly to me for urinary incontinence and I think that's appropriate. Many patients prefer to see a physician they already have a relationship with like their primary care doctor or their gynecologist or they can come straight to see an urogynecologist.

Nada Youssef: Now, would you say this disorder is like a normal part of aging for women?

Katie Propst: Increasing age is a risk factor for urinary incontinence but it's not a normal part of aging.

Nada Youssef:  It's not normal. Then, so causes it could be like age, can overweight-

Katie Propst: Yes. Obesity can contribute to urinary incontinence and there are studies showing that patients who are overweight who lost weight can actually improve their urine leakage in the case of stress incontinence.

Nada Youssef: Now, I know a lot of women that may be after having kids, after especially having multiple kids that will say that they will urinate a little bit after sneezing or anything like that. When is it normal and when is it like, this doesn't sound normal, I need to go see a doctor.

Katie Propst: In general, that's not normal, I would say. Whether or not to seek treatment depends on how bothersome it is. Some patients may find that they have that leakage once a month and they don't feel that it's bothersome. They probably don't necessarily need treatment. However, if someone's leaking multiple times a day and finds it bothersome, then an intervention or a treatment might make sense.

Nada Youssef: And just like you were talking about quality of life, if it's really-

Katie Propst: Exactly. It's all about how the leakage affects the patient's life and if they find it to be bothersome.

Nada Youssef: Great. How about medications? Can medications cause incontinence? Because I feel like I've read a lot about that.

Katie Propst: There definitely are medications that can cause or worsen incontinence, and that really depends a lot on the patient's specific situation, their anatomy and what other risk factors they have and total what medications they're using.

Nada Youssef: Sure. Before I keep going, I am getting some live questions, so I'm going to read some of those out here. First, I have Mike. My mother-in-law has a situation where urine leaks uncontrollably, she's done several tests and nothing could be found wrong with her. What could be the problem?

Katie Propst: Well, it's hard to know specifically because we don't have a lot of details of Mike's mother's symptoms. But I think in this case, oftentimes, this is where the history is really important to understand when the leakage is happening. Maybe nothing is wrong in terms of a specific cause for the incontinence, so it may be stress urinary incontinence or overactive bladder. So I think further evaluation perhaps by gynecologist or urogynecologist could be useful in this situation.

Nada Youssef: Very good. Thank you. Then I have Carla. I had that TOT procedure about eight years ago, it is no longer working. I leak all the time and is there any type of physical exercises to strengthen the bladder? Before I let you answer, if I can have you tell us what is a TOT procedure for those who don't know?

Katie Propst: Sure. That's a great question. The TOT procedure is a type of sling that's used to treat stress incontinence. TOT just has to do with how the sling is placed. Now, the reason that Carla's still having leakage many years after her TOT procedure could be for several reasons. It could be that she has more than one type of incontinence, it could also be that the sling is no longer working. So she would need further evaluation to determine what the case is. What I would say though to the question about exercise is to help with the leakage, pelvic floor exercises or Kegel contractions can help with urinary incontinence.

It's important to understand how to use the exercise to help the incontinence. It's important to exercise the muscles regularly to make them strong, to have good control of them, but just doing those contractions won't help the incontinence. The Kegel exercises have to be used at times of stress activities that cause leakage or to suppress urges for overactive bladder. So it might be useful for Carla to follow up with her urogynecologist or gynecologist to determine what type of leakage she's having so we can best understand how she should use those exercises to improve her leakage.

Nada Youssef: Great. And speaking of that, what lifestyle choices can worsen incontinence?

Katie Propst:  There are definitely things we can do in daily life to make incontinence worse and that's drinking excessive fluids can certainly worsen incontinence. We know certain things can irritate the bladder like alcohol and caffeine and smoking, so often these are important components in treating urinary incontinence.

Nada Youssef: Very, very good to know. Thank you. Then I have Barbara. I'm a 70-year-old with two children, no dribbles yet but what can I do to stop them in the future?

Katie Propst: That's a great question. I think for anyone having good bladder hygiene as we just talked about some of the things that can actually worsen bladder function like avoiding excessive alcohol and caffeine and avoiding smoking or quitting smoking can help prevent these things in the future. And also those Kegel exercises can help keep the pelvic floor healthy, so that can be helpful as well.

Nada Youssef: Great. Then for Kegel exercises, is it just like normal to just kind of like YouTube what to do or do you go purchase something or program or what do you suggest?

Katie Propst: That's a great question. I think that varies per patient. Some patients are very good and able to easily squeeze the pelvic floor, others may have difficulty locating those muscles or contracting them at all. So I think it's reasonable to try videos, that's fine. I think there are some devices available on the market to give you feedback if you're actually squeezing the muscles. I think when you see your gynecologist to say, can you check my Kegel squeeze and tell me if I'm squeezing the right muscle can be really helpful. Patients who can do a good squeeze, practicing at home is reasonable.

Nada Youssef: Sure.

Katie Propst: For those who have a hard time identifying the muscles or squeezing at all, sometimes pelvic floor physical therapy can be really helpful in those situations.

Nada Youssef: Kegel exercises can be used by any female, you don't have to go through incontinence to do it. Is that correct?

Katie Propst: That's correct.

Nada Youssef: That's a good muscle to exercise.

Katie Propst: Absolutely.

Nada Youssef: I have Noberta. Can you talk more about bladder prolapse?

Katie Propst: Prolapse is a condition where the pelvic organs and in this case that we referred referencing is the bladder, herniate or bulge down into the vaginal canal. This has a number of treatment options. One, like urinary incontinence is to just observe the condition if it's not bothersome. Exercises can be helpful. There are devices that can go in the vagina to support the prolapse and we also have surgeries that we can use to treat prolapse as well. I think in the case of bladder prolapse, it would be appropriate to be seen by urogynecologist.

Nada Youssef: And while we're talking about treatments and solutions, can we talk about those treatments and solutions and lifestyle changes that we can do as women to prevent from happening.

Katie Propst: That's a good question. So we talked a little bit about some of the lifestyle things in terms of managing fluids, not drinking excessively, avoiding excessive caffeine or alcohol and avoiding smoking. I think also there are concepts of good bladder hygiene in terms of going to the bathroom somewhat frequently, but sometimes if we go too frequently, that can reinforce an urgency pattern for the bladder.

Nada Youssef: Really?

Katie Propst: It can. And if you have questions about what's a normal bladder function, that's a good thing to talk about with your gynecologist.

Nada Youssef: Then for incontinence, would you talk about like weight loss, things that we can do, physical therapy, things like that as well.

Katie Propst: Weight loss can be helpful in some situations especially for stress incontinence. Physical therapy can also be helpful. As I mentioned before, I think that's most helpful for women who have trouble controlling those pelvic floor muscles.

Nada Youssef: Sure. I know in our health essentials health site for Cleveland Clinic, we talk about this tampon looking device for urinary incontinence. Can you talk a little bit about that?

Katie Propst:  So there is a device that you can purchase over-the-counter that's inserted into the vagina like a tampon, and once placed it expands in an effort to support the urethra. So it's a way of supporting the urethra while avoiding surgery, and that would be for stress incontinence. So leakage with activity, coughing or sneezing or running. I think this device is most useful for women who have very specific activities that provoke the incontinence. For some women, they may only leak when they exercise or jump on the trampoline with their children and maybe that's the time that they use the device.

Nada Youssef: So it's not like a daily thing. You use it when you're highly active?

Katie Propst: Exactly. I think it could be used daily but most women find that that kind of maintenance, it would be cumbersome, but it could be used daily.

Nada Youssef: And when do you think surgery is needed then?

Katie Propst:  When to proceed with surgery really is based on that impact on the patient's quality of life. Typically, what I like to do with patients is understand how things are impacting their life, review the treatment options and then give them a choice of how they like to proceed. Some patients are ready to proceed directly to surgery when I've met them and others feel that it's not warranted and want to try Kegel exercises or one of these devices that we're talking about.

Nada Youssef:  All right. I have Carmen. What can you do to control stress incontinence? I know we kind of talked about some of this stuff.

Katie Propst: Yeah, we've mentioned that some of those things.

Nada Youssef: Then you mentioned not smoking. Can you discuss the connection of smoking and the bladder?

Katie Propst: That's a great question. That connection is not well understood. What we believe is that most likely that there are byproducts of the nicotine that are excreted in the urine and those byproducts irritate the bladder and cause contractions within the bladder wall.

Nada Youssef:  The byproducts, like what are we talking ... Are we talking about like the toxins coming out?

Katie Propst:  Correct.

Nada Youssef: I see. Very, very good. Then Cindy, can the bladder tuck could be done more than once?

Katie Propst: Well, I think Cindy's referring to a repair of a bladder prolapse and that can be done more than once.

Nada Youssef: It is. Okay. Then Melinda, does wearing a pessary help bladder issues? And what is that? I guess, I'll ask.

Katie Propst: That's a good question. A pessary is a silicone device that's placed in the vagina. Typically, they're used to support prolapse, so that's the bulging of the pelvic organs into the vaginal canal. Some pessaries are made to help with urine leakage and those are stress incontinence pessaries, they help to support the urethra and they can certainly improve urine leakage with activity. Often they don't allow complete resolution of the leakage but they can't help. Sometimes when patients have prolapse of the bladder, they can also develop urinary urgency or incomplete bladder emptying. So sometimes the pessary can help by supporting the bladder better, it allows for a better bladder emptying and improvement of that urgency and incomplete emptying.

Nada Youssef: Sure. So from what you've said before, you're saying that muscles usually is the biggest culprit here. Is that including not being able to empty your urine? Would that also be a muscle issue or is that something else?

Katie Propst: It could be not being able to empty your bladder well has many different causes, but say the pelvic muscles aren't working well and therefore the bladder isn't well supported, sometimes the bladder doesn't empty well, the bladder can pull urine because it's in an abnormal position.

Nada Youssef: Okay. I have Melinda. Do all women get this problem? Can you share some treatment plans?

Katie Propst: Not all women develop incontinence. For women who have overactive bladder or that's the leaking with the feeling of needing to go urgently and frequently, those women often we do a stepwise treatment approach. So we first we'll discuss behavioral treatments that we've talked about. Sometimes I have those women do a bladder diary and that helps us to identify things in their daily life that may be making the incontinence worse. If that's not helpful, there are some medications we can try, and if medications aren't helpful there are some procedures available to help with overactive bladder and urge leakage. For women who have stress incontinence, we've reviewed some of those treatments such as the pelvic floor exercises, the pessary or the tampon device, and then we have some surgeries available as well.

Nada Youssef: Now bladder diary, I'm curious. Tell me what kind of things just like how many times you go if you're leaking-

Katie Propst: Yes. So a bladder diary is helpful in patients who described incontinence that doesn't fit a particular diagnosis, or in whom we think that some of their behaviors may be playing a big role in their bladder problems. So I typically have patients do a two-day bladder diary where they record how often they go to the bathroom, I'll have them record how much they peed, actually the volume of urine and they also will record when they leaked and what they were doing and how much they drank.

Nada Youssef: To try to figure out exactly what kind of incontinence they have.

Katie Propst: Correct.

Nada Youssef: Then I have a question from Khalil. Can incontinence be prevented?

Katie Propst: That's a great question. It depends a little bit on each patient's situation but it can be prevented I think with some of the lifestyle factors that we've discussed.

Nada Youssef: Great. And Deb, my doctor suggested I try not drinking tea and it worked, why? Is it caffeine?

Katie Propst: Likely. Yes. It's probably the caffeine and it may also be a volume issue as well. The caffeine may have irritated the bladder and as she eliminated tea, she may have had a reduction in the amount of fluids she was drinking. That also likely helped.

Nada Youssef: So caffeine does irritate the bladder?

Katie Propst: It does.

Nada Youssef: That's the product itself.

Katie Propst:  It irritates the bladder, it also is what we call it diuretic, which means it causes us to make more urine. It increases the urine production in the kidneys. So not only does it irritate the bladder, there's more volume of urine.

Nada Youssef: I see. All right. Very, very good to know. Then Joyce, should you stay away from diet pop? Everybody should stay away from diet pop but I'm not really sure. Does it have to do with urinary incontinence?

Katie Propst: It can irritate the bladder. So there are some well-known bladder irritants, diet pop is one of them because it may have caffeine in it, artificial sweeteners can also irritate the bladder. And we know in some patients, carbonated beverages, the carbonation can be irritating as well.

Nada Youssef:  All right. Then Drinda, What success have you found with bladder pacemaker?

Katie Propst: The bladder pacemaker. That's a great question. I think that she's referring to a device that's currently being researched. There's a bladder pacemaker that is being studied here at the Cleveland Clinic to measure bladder pressure and this has some potential applications for controlling the bladder urges and for measuring pressure in the bladder to evaluate what's going on before we can provide treatment to get the right diagnosis. This is a device we're studying. So it hasn't been studied yet in humans, so we're still ... It's not currently available to patients but it's something that maybe has promise for the future.

Nada Youssef: All right, so we'll stay tuned for that. Then Trina, what about exposure to cold or bare feet on cold floors that cause a sudden urgency to urinate and dribbles begin.

Katie Propst: That's a great question. I don't know the mechanism for this. I definitely have patients who describe this to me. I do think it's probably a component of urge incontinence, but I don't know the mechanism for the trigger.

Nada Youssef: I mean, I could think about it, like just being cold, you feel like you want to urinate more. Gayla, what can I do about bladder spasms? I start to leak when my brain knows I'm headed to the bathroom.

Katie Propst: That's a great question. So what Gayla is describing is overactive bladder and urge incontinence. So much about diagnosing types of urinary incontinence has to do with patient history. It sounds based on this small amount of information that this is probably overactive bladder, so I think evaluation with a physician would be warranted in this situation to talk about treatment.

Nada Youssef: Great. Then Terry, can this condition be hereditary? Is there any link to family history?

Katie Propst: We do believe so. Especially for overactive bladder, we find that this does tend to run in families.

Nada Youssef: Then I have Jeanie. Does a prolapsed bladder cause UTIs?

Katie Propst:  That's a tough question. In some women, if the prolapse is severe and the bladder isn't emptying well, sometimes the urine pulls and doesn't empty and that can be a risk factor for urinary tract infections. But many patients who have that condition also have other risk factors for urinary tract infections. So sometimes it's related.

Nada Youssef: So UTI, is that a usual symptom of urinary incontinence?

Katie Propst: Not typically. I would say generally, urinary incontinence can happen because of a urinary tract infection, but typically that would be more acute or quick and onset. So patients who've had leakage of urine for five years probably it's not from a urinary tract infection. Incontinence doesn't cause urinary tract infections.

Nada Youssef: Okay. Good to know. Very good. Then Barbara, I get chronic UTIs, is there a natural preventative?

Katie Propst:  That's a good question. Not very easy to answer. I don't think that there's a natural preventive that we know of-

Nada Youssef: Not cranberry juice.

Katie Propst: Not cranberry juice. I mean, the data for cranberry tablets and cranberry juice is very mixed. What I would say is it's probably not harmful to use cranberry tablets, but it may not be helpful. In terms of cranberry juice, there's a lot of sugar in juice. So when we think about those things, it maybe is not the best idea for your overall health depending what other medical conditions you may have.

Nada Youssef: Very, very good information. Thank you. Then Melissa. Just tuned in. I had my first baby and it was a C-section. Is it normal to now have bladder issues?

Katie Propst:  We need a little more information to be able to clarify this exactly. But what I would say is urinary problems aren't uncommon after delivery even after C-section. We know that typically urinary incontinence that occurs after delivery does tend to get better with time. So it depends a little bit on the specific delivery situation and how long it's been since the birth. But I think if it's not improving with time after several months from delivery, it would be a good time to get an evaluation.

Nada Youssef: Why do bladder issues not matter if you get a C-section? Is it just the pressure of pregnancy or what is it?

Katie Propst:  Well, what we know is that pregnancy in general puts some pressure on those pelvic floor muscles that are so important for bladder function, and there's more pressure on the pelvic floor muscles at the time of vaginal delivery versus C-section. So probably there are more bladder issues after a vaginal delivery than a C-section.

Nada Youssef: Good. Now, I wanted to ask you also, what role does the pelvic floor muscle play in bowel problems? Because I know here in the Cleveland Clinic, there's a multidisciplinary approach to this, correct? Can we talk about that a little bit?

Katie Propst:  That's true. Within the urogynecology division, we do collaborate with colorectal surgery and urology and gastroenterology to manage problems that are more complex. So in some patients, there may be problems with the bowels and the pelvic floor and sometimes surgery from a team approach is warranted.

Nada Youssef:  That's great. I have a few more questions for you. I have Tammy. How often should you do pelvic floor exercises and how many minutes a day? You're going to say it depends, aren't you?

Katie Propst: It does depend a little bit. But there are some basic tenets that are important to observe. In the same way when you go to the gym, you don't start out by running a full marathon the day you start. So I would recommend anyone who's practicing to begin with fewer repetitions and then to slowly work up, the same way you would train any muscle.

Nada Youssef: Great. Then Anita. The testing seems archaic or old-fashioned, is there any other way to get a diagnosis?

Katie Propst: Well, it depends a little on the patient situation. This questioner, Anita, may be referring to urodynamic testing which is pretty invasive that we perform in the office. And what we try to do within our division is perform this testing only when it's warranted. So if we're able to get a history and a physical exam that clearly supports a diagnosis, often we're able to move forward without doing formal testing. It really depends on that specific patient situation.

Nada Youssef: Sure. All right. Then I'll have ... Sorry. One more question for you. I have Julie. Can these disorders lead to complications with pregnancy?

Katie Propst: Not typically. If we're talking about urinary incontinence, that doesn't usually cause complications in pregnancy.

Nada Youssef: It does not.

Katie Propst: No.

Nada Youssef:  All right. One more came in. So Brenda one more chance here. I'm 66 now and when I have to pee, I must go right away. As a young person, I could hold it much longer. What is wrong?

Katie Propst: Well, there are several things that could be going on. It may be that the pelvic floor muscles have become weakened over life and so it's harder to use them to control the bladder. It also could be as we talked about overactive bladder is a condition that can cause urinary urgency and frequency. So it's hard to know exactly what the problem is, but there are a couple of different things that could be going on.

Nada Youssef:  Right. All right. Well, we're all out of time but before I let you go, is there anything else you wanted to share with our audience? Did we talk about everything?

Katie Propst: I think we covered everything. Thanks for tuning in.

Nada Youssef: Sure thing. Thank you. For more information on female incontinence or to make an appointment with a Cleveland Clinic physician, you can call us at 216-444-6601. And for more health news and information, make sure you follow us on Facebook, Twitter, Instagram and Snapchat @ClevelandClinic. Thank you. We'll see you again next time.