Regaining Confidence: A Look at Incontinence

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're shedding light on a condition many women experience, but often hesitate to talk about. Urinary incontinence. Urinary incontinence can affect women at any age, after childbirth, during menopause, or simply as your body changes over time. And while it's incredibly common, it's not something you just have to live with. I'm joined by urogynecologist, Dr. Amy Park, to discuss the different types of urinary leakage, what can contribute to it, and how to manage it. Thank you so much for joining me on the podcast, Dr. Park.

Amy Park, MD:

Thanks, Dr. Newlin. I really appreciate being able to come here today.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role in the Cleveland Clinic and your background?

Amy Park, MD:

I am a urogynecologist and I trained in OB/GYN at University of Pittsburgh, McGee Women's Hospital. And then I did my fellowship here actually in urogynecology and reconstructive pelvic surgery. I actually practiced in Washington DC for 11 years at MedStar Washington Hospital Center. I was associate fellowship program director there and director of research. And then I was recruited back here in 2020, actually the week that the pandemic shut down elective surgery, that's the week that I came back. So I've been here now almost six years come March and I'm just delighted to be back here.

Erica Newlin, MD:

Yeah, for sure. We're happy to have you here. Let's begin with the basics. What is urinary incontinence?

Amy Park, MD:

Urinary incontinence is the involuntary loss of urine. There's a couple different types. There's stress incontinence, urge incontinence, mixed incontinence, which is a combination of both. There's also older terms like overflow incontinence when people don't completely empty their bladders, but I'm not going to focus on that for the purpose of this discussion, just because it's a relatively rare subtype.

Erica Newlin, MD:

How common is leaking urine among women?

Amy Park, MD:

The prevalence increases with age, but basically about 50% of US women experience stress incontinence over the course of their lifetimes. But the prevalence really increases from about 15% in younger women in their 20s to over 75% for women who are in their 70s. So it's quite a prevalent condition overall, but I think there's just a lack of awareness regarding that it's not exactly normal and there's treatment options available.

Erica Newlin, MD:

You're right. A lot of women in my office are like, "Oh, I leak urine, but it's normal." Can you kind of differentiate what's normal versus not?

Amy Park, MD:

The leaking urine is not normal. I think a lot of women just accept it as part of aging, but we don't have to accept that, just like we don't have to accept wrinkles apparently anymore. Although I will put this in a more functional category. It is actually quite prevalent, as I mentioned earlier, especially the stress incontinence, but also urge incontinence and mixed incontinence. So I usually tell patients it's not normal. There are treatment options. I just think there's a lack of awareness, generally speaking, that they don't have to suffer with it.

Erica Newlin, MD:

For sure. And you've alluded to the different types of incontinence, but can you go into a little more detail on the difference between stress versus urge and how someone might recognize one versus the other?

Amy Park, MD:

Stress incontinence is the leaking with coughing, sneezing, laughing, exercise. There's two different types of urge incontinence, broadly speaking. Urgency frequency nocturia, where patients go to the bathroom eight or more times a day or one or more times at night, and then there's the type where people can't make it to the bathroom in time and they just have some urgency and then they lose their urine. Mixed incontinence is a combination of the two. I would say that those are the patients who I feel like actually seek the most care in my practice at least and my practice in DC. But actually, I would say stress incontinence is the most prevalent with the coughing, sneezing, laughing.

Erica Newlin, MD:

What does cause that leaking over time with the coughing, sneezing, laughing?

Amy Park, MD:

The risk factors for all the different types of incontinence, stress, urge, mix, have similar risk factors. Age, just as we age, we lose our muscle mass and our connective tissue gets less elastic. Family history, especially urge is very genetic, but also the shape of our pelvis and the positions in which the childbirth occurs in terms of fetal head positioning and then how long our perineal bodies are and our muscle types and then connective tissue disorders and how that plays in. And then obesity, because just a lot of pressure on the pelvic floor, any kind of conditions that cause increased pressure on the pelvic floor, like chronic cough, like I mentioned, the obesity. And then the biggest one is childbirth injury, but even just pregnancy can cause a lot of loosening of the connective tissue and the ligaments. So I've definitely seen patients who have not given birth, who are nulliparous have issues with incontinence.

But the biggest risk factor is if patients have undergone assisted vaginal delivery with either forceps or vacuum or have had a higher degree tear, like a third or fourth degree tear, which is just reflective of increased damage to the pelvic floor. I tell patients it's just, you know, if you think of the average weight and size of a baby, it's like this size of a bowling ball or watermelon coming through the pelvic floor. So when the husbands are present, I say, "Well, imagine a bowling ball coming through the rectum." That would obviously cause some damage your pelvic floor muscles and your anal sphincter and that's the same thing that happens to the vagina. It incurs damage to the underlying connective tissue, ligaments and pelvic floor muscles. So when I put it in that kind of sense, I, I think people really understand it.

At one point, a couple years ago, I remember not feeling good and I looked at my son who might have been seven or eight at the time and I said, "You ruined mommy's body." And he's like, "I know. " And which is so funny because it's sort of intuitive that, you know, even to children, when you look at a pregnant woman, like that's a lot of stress on your body and it can be really hard time for each time. And then we're not talking about prolapse in this podcast, but, you know, there's studies showing that each delivery increases the leading edge of prolapse by like a centimeter. I mean, that just shows that each time this happens, it's an insult, an injury to us It is multifactorial, but having said all this about vaginal delivery, we're not quite at the point where we would try and recommend elective C-sections just to avoid it because there's also a lot of risk associated with repeat C-sections.

Like 50% of our pregnancies in the US are unplanned. You get into the risk of placenta accreta, which is where there's abnormal implantation of the placenta into the uterus or it can even extend into the bladder or the rectum. So we, we don't want to encourage that necessarily, but there's a lot of studies looking at what can we do? Like is there special cushioning techniques or should we labor down, which is letting the baby sit in the pelvis for a little bit before we have patients push. And honestly, none of those things have shown any prevention or benefit. So we're really at the infancy of understanding mitigation techniques.

Erica Newlin, MD:

For sure. Can you explain a little about what is the pelvic floor? What do we mean when we refer to the pelvic floor?

Amy Park, MD:

If we think about our pelvic bone, I usually tell patients it's like a muscle diaper that keeps everything in and it's connected to our back and our hips. Our abdomen and pelvic cavity are all connected. It supports our vagina, the rectum, the bladder, but it also keeps all the pressure in, in terms of intraabdominal pressure, pelvic pressure, it's all one cavity. The function of it is to support our pelvic organs, but it also helps stabilize our back and our hip muscles, anything that affects any of those areas our uterus, bladder, rectum, like underlying back problems or hip problems can cause people to go into pelvic floor spasm sometimes, or also just weakness. And then the other thing that I want to just talk about is not only are we talking about muscular issues, but any kind of underlying neurologic issues can affect urinary function.

If patients have underlying spinal cord issues, herniated discs, spinal stenosis, neuropathy from diabetes, Parkinson's, multiple sclerosis, history of stroke, continence is a very complicated mechanism. Our brains basically, their cortex, which is the outside of our brains, really have to process all sorts of stimuli like, "Hey, I'm in the bathroom. It's okay to urinate here." And all of those signals go down our brainstem into the pontine micturition center, down our spinal cord, into the nerves, and our bladders have to contract our urethra and pelvic floor muscles have to relax. But anything that interferes with that signaling process, that highway, I would say, like causes a traffic jam, it will affect our continence mechanism. Continence, meaning our ability to keep urine inside the bladder and not leak at an inappropriate time. So we have to keep all of that in mind in terms of like the muscles, but also the nerves and what is the underlying issues, and then also if there's any medications that can affect urinary function.

Erica Newlin, MD:

Now that we know what urinary incontinence is and why it happens, let's talk about how it affects daily life. What symptoms should prompt someone to seek care?

Amy Park, MD:

Well, this is a quality of life issue and I give people the, just like I gave that analogy of having a dilation injury to the pelvic floor, I tell people, this is a quality of life issue. You do not need to suffer. If it doesn't bother you or you're asymptomatic, I would say don't worry about it. But if you are having what I like to call intrusive thoughts, like, "Oh, I'm not exercising because I'm leaking." Or, "I don't want to go to church or I don't want to go to Playhouse Square or I don't want to watch a movie because I will have to go to the bathroom multiple times or I'll leak or I don't want to wear pads anymore." Then it's time to seek care. Warning signs where I say, you know, you should definitely get treated is when patients are starting to have problems with recurrent urinary tract infections or incomplete bladder emptying and retention, that can eventually cause issues with kidney function.

That's more of an issue really for men though than women, because women usually leak out before they will have backup through our tiny little tubes that go back up to your kidneys, it's like to have retrograde flow from your bladder opposite gravity up these little tiny tubes into your kidneys, that would be pretty unusual unless you had some sort of obstruction. A lot of people do have concomitant prolapse though, so I would say that scenario, we just need to evaluate and make sure that people are emptying their bladder completely and we can do that in the office pretty easily with a bladder scan. But usually I just tell people, this is a really bothersome quality of life issue and come in for evaluation. If people choose to have treatment, that's great. If not, that's also fine, in OB/GYN and just in women's health and in medicine generally, we engage in a lot of shared decision making.

So I like to tell patients there's a lot of different options and we can tailor this individually to what you're comfortable with and what you want to do.

Erica Newlin, MD:

We've talked about the symptoms and daily impact, but as you mentioned, it's treatable often without surgery. What are the most common treatment options for urinary incontinence?

Amy Park, MD:

For stress incontinence, that's the leaking with the coughing, sneezing, laughing, exercise, either we can fit patients with a incontinence pessary, which is an intravaginal support device. It has a little knob that supports the bladder neck, so when they cough, sneeze or laugh, it's a backstop against which the urethra can compress. Usually patients can manage them on their own. We have our nurse practitioners fit them in the office. Another option is looking inside the bladder with a small lens and camera and injecting polyacrylamide gel. It's 97% water, it's 3% polyacrylamide, but I tell people it's kind of like fillers for their wrinkles at the bladder neck. So when people cough, sneeze or laugh, it stays closed. It creates these cushions at the bladder neck. It usually results in about 65% improvement, but only about a quarter of patients are dry. Most women at seven years, which is the longest follow up we've had, need between one and three injections.

And then the most durable and highest curate is the sling. It's a small piece of mesh. It's put underneath the mid-urethra, so when the patient's cough, sneeze or laugh, it's a backstop against which the urethra can compress. It usually results in a 70 to 80% cure rate for the stress incontinence. Urge often improves, but it just worsens about 5% of the time. And I tell patients it probably lasts about 10 to 15 years, although we do have good 17-year data, but just like any other kind of reconstructive surgery in the body, it just doesn't always last forever. Like I give the analogy of the facelift or the knee replacement or hip replacement. So I'm hoping on the horizon there are other, you know, regenerative therapies, maybe stem cells or something down the line, but it's really been these similar options for the last 20 years.

For the urge or the urgency frequency overactive bladder symptoms, I usually counsel patients on avoiding bladder irritants, things like coffee, tea, soda, alcohol, trying to do the time voiding every two to three hours while they're awake. At night, just get up when you have the urge to urinate. If they're postmenopausal and they have signs and symptoms of the genital urinary syndrome of menopause, I usually recommend some vaginal estrogen cream, which is very safe. The safety profile is so safe. In fact, the FDA just took away the class warning, the black box class warning on estrogen, but it really has very minimal systemic absorption and it can help with urinary symptoms because there's a lot of estrogen receptors in the bladder and urethra as well as the vagina. We can also prescribe medications. Anticholinergics affect the muscarinic receptors in the bladder. It just basically relaxes the bladder muscle.

It does have a side effect profile of dry eyes, dry mouth, constipation, because those receptors are other places in the body and they're not selective necessarily. If, then the contraindication is glaucoma or incomplete bladder emptying. The other class of drugs that we can try are beta three agonist, those relax the bladder as well, the bladder muscle. Usually we have to try anticholinergics first just for insurance reasons. I always tell people, "I didn't make this system. I just live in it. " The other thing we can do is refer patients for pelvic floor physical therapy. So doing the Kegel exercises, learning urge deference techniques, so when they feel the urge kind of squeeze and let go, squeezing let go, let their urge sensation subside and then walk, not run to the bladder. I tell people it's kind of like running for a 5K. Like, you know, when you start running, you can't like hold things right away.

It's not like your lung capacity actually gets bigger, but your functional capacity increases. We have to help people hold more urine in their bladder sometimes. And then if patients either fail medications or they have underlying neurologic disease, like I mentioned before, we can go to the botulinum toxin. And what we do is we look inside the bladder with the cystoscopy, which is a small lens in camera after we numb out the bladder and give patients some phenazopyridine as a bladder analgesic and just put the Botox into the bladder muscle and wall and it usually starts kicking in at three days. People have maximal effect at seven to 10 days, usually results in 70 to 80% improvement in urge symptoms and then it lasts on average six to nine months. So I tell people it's just like going to the dentist, accept this one. Hopefully we can ... And I try and put this in functional terms for our patients.

Like I would love to get you out of diapers or Depends into pads or pads to panty liner or nothing because it's really bothersome for people to have to buy them and it's quite expensive actually. And it allows people to not have to do these adaptive behaviors like fluid restriction, bathroom mapping, you know, stopping by home and they can't be out all day. Or like I said, not being able to go to church or the movies or things like that and they're just fearful of smelling like urine. So it really gives patients their lives back. And then one other option is sacral neuromodulation and then there's another one that's like implantable tibial nerve stimulation. That one affects the nerves that supply the bladder and bowel and help people with the urge. So that's another therapy that's available.

Erica Newlin, MD:

I've had some patients come to me with concerns about the neurologic side effects of some of the urgent continence medications or those risks. Can you speak to those?

Amy Park, MD:

Yeah. So with the anticholinergics, there's an increased risk of dementia and it's cumulative anticholinergic burden. I've seen exposure risk increase either at three months. I've also seen it at one year or three years, but essentially in my practice, we try and move patients off of the anticholinergics as much as possible if they don't have a response. Because the anticholinergics, about a third of patients have a complete response, a third have a partial response, and a third have no response. So two thirds of patients are really having not great responses or no response. For the third that do have a response, well, I'll keep them on it, but if patients have a history of cognitive decline or dysfunction or have a history of dementia, I really try and avoid it if possible.

Erica Newlin, MD:

How important is early intervention? Should someone come early in their symptom process or wait for it to become a quality of life issue?

Amy Park, MD:

I think that's just a personal choice. I've had patients have not that much leakage, but they're very bothered by it. And I have patients who leak a lot and they're not bothered by it. So I think it's an individualized choice. Just like when we counsel patients about different options for, I don't know, birth control and bleeding and things like that. I think patients should just come when they're bothered because if they're completely asymptomatic, then I tell people, it's just like seeing on x-ray on if somebody has osteoarthritis, but they're not bothered or have any functional limitations, then, you know, we don't have to treat it if we don't want to. But what ends up happening, I think a lot of the time is patients tell themselves it's okay, and then they sort of, it's insidious onset, and then they end up not exercising, then they gain weight, and then it makes their urge and stress incontinence worse.

I just want to encourage people to seek care, and I can go over options with them in the office, and then at least they know, and then they can come back. But the other modifiable risk factor, like I said, is this obesity, and that has been historically a very tricky topic and I think now with GLP-1s, you know, if you're a candidate for that, I think it offers people a lot of better options. Now, our understanding of obesity is getting more complex and there's better treatment options than having, like, a big surgery, like bariatric surgery with a gastric sleeve or they Roux-en-Y, gastric bypass. So I think that that's another thing that patients can undertake if possible.

Erica Newlin, MD:

Are there any home remedies or over-the-counter options that can help with incontinence?

Amy Park, MD:

There's these biofeedback devices that they kind of look like a tampon and then it's Bluetooth and gives you feedback if you're doing your Kegels correctly. There's biofeedback, pelvic floor stimulators, there's TENS units. I haven't seen the efficacy profiles for all these at-home treatments, but oftentimes those patients end up coming to me because it just doesn't confer lasting results.

Erica Newlin, MD:

Can urinary incontinence be prevented? Are there any proactive steps that people can do to prevent incontinence?

Amy Park, MD:

Yeah, I think the main things would be keeping the weight down and then keeping the muscle mass up, so exercises. So any kind of core strengthening activities like yoga, Pilates, bar. I had a patient who started Taekwondo and she said that after she became more active, it, it really helped her. So I think keeping muscle mass is just such an important anti-aging tool, weightlifting and weight bearing activities. I mean, even pregnancy can be confer risk, so to develop pelvic floor disorders in the future. I think those are the main things. There's not much we can do about our genetics. In terms of the behavioral modifications, like I said, just avoiding the bladder irritants and like caffeine makes people have more urgency symptoms since it's a diuretic and it's a bladder irritant. Diuretics makes you produce more urine. And then if patients have diabetes or underlying neurologic disease, just keeping the diabetes under good control, because if the sugars are too high, then that spills into the urine.

It makes people relatively dehydrated because people produce more urine and then they drink more and then it also affects their nerves and their hands and feet, but also the nerves supplying the bowel and bladder. So that's important. And then any underlying disease, like I've had patients whose Parkinson's wasn't well controlled, but then once they had it on a more ideal regimen, their urinary symptoms improve. Same with MS. And then if people have underlying inflammatory bowel disease, sometimes that inflammation can cause issues, even though we're talking about the bladder, but, you know, they can have sequelae from their pelvic pain or what have you. I mean, because there's a, actually, I didn't even talk about this, but if people are having a lot of pelvic floor spasm, it can cause people to have like an overlapping syndrome of having urinary urgency and painful urination and having some painful sex because they're just, their muscles are just so tight.

Just like when people have, I get like spasm in my shoulders and my neck and it feels like a burning sensation, that can happen in the pelvic floor muscles as well. So it's important to diagnose and treat that.

Erica Newlin, MD:

What's your advice for women who feel embarrassed to talk about this?

Amy Park, MD:

Well, our office is very confidential. You know, we don't require referrals to come see us. I wish there weren't access issues because I think there's wide swaths of the US where there aren't urogynecologists available, but friendly urologists often can initiate treatments and I have wonderful female urology colleagues here who also treat the same conditions. I think that that is an issue for a lot of the US and especially rural areas in terms of accessing treatment, but no need to feel embarrassed, feel free to come see us at Cleveland Clinic.

Erica Newlin, MD:

Before we close, are there any misconceptions about urinary incontinence that you'd like to clear up?

Amy Park, MD:

I think we touched on a lot of it that it's normal to leak, there aren't treatment options, that wearing pads is normal. But I think that the other thing to know is that a couple years ago, there was a lot of worries about the mesh sling, and I just want to reassure patients that the mesh sling is considered the gold standard surgery by all of our major national societies. It's been the most studied anti-incontinent surgery of all time. In all of the randomized surgical trials comparing the sling to older traditional repairs, better cure rates, less blood loss, less operating room time, earlier return to regular activities, and is very durable. So I want to just reassure patients that it's very safe, it's very effective, and it's minimally invasive. We still do a lot of them and recommend a lot of them. I would just recommend that patients seek care from a high-volume surgeon that is able to diagnose and treat and does this on a regular basis.

Erica Newlin, MD:

For women listening today, what's your biggest piece of advice when it comes to urinary incontinence?

Amy Park, MD:

Well, you know, there's a lot of things that you can do on your own, like I talked about, but in terms of other options, please seek care. And I know here we have a very high awareness in our institute and I think among internal medicine folks. The other thing that I always tell people is if you have friends or family who work in hospitals, they can point you in the right direction of like who to see because that's something that's actually hard for people to know sometimes like where to seek care.

Erica Newlin, MD:

Well, Dr. Park, thank you so much for joining me on the podcast today. For more information on urinary incontinence, visit clevelandclinic.org/urogyn. That's clevelandclinic.org/U-R-O-G-Y-N. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your bladder health is a powerful first step toward feeling more confident, comfortable, and in control.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.