More Than a Weak Bladder: Understanding and Treating Incontinence

Intro: This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here’s Deborah Howell.

Deborah Howell (Host): Hello, welcome, welcome. You're listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I'm Deborah Howell, and today our guest is Leah Nakamura, MD, a urologist with fellowship training in female pelvic medicine and reconstructive surgery. Today's topic is understanding and treating incontinence. Welcome, Dr. Nakamura.

Leah Nakamura, MD: Thank you. I'm very happy to be here with you this morning.

Deborah Howell (Host): And we're happy to have you. Now, over 25 million Americans are affected by incontinence. That is a staggering number.

Leah Nakamura, MD: It sure is, and it's going to continue to grow as incontinence does affect our elderly population, which as we know is growing and growing by the minute.

Deborah Howell (Host): So let's get to the bones of it. What is incontinence?

Leah Nakamura, MD: So when we're talking about incontinence, we're talking about urinary incontinence today, which is defined as specifically the involuntary loss of urine, or more in layman's terms, it's what people say when they quote "wet their pants" or quote "have an accident," or you know if they "pee themselves."

Deborah Howell (Host): Okay, okay. So it's not a pleasant situation for anyone.

Leah Nakamura, MD: No, definitely not.

Deborah Howell (Host): And so what are the different types of incontinence, and which are the most common?

Leah Nakamura, MD: So incontinence can be broken down into several different types. The main types are divided in two big categories that are most common, and that is the first category we refer to as stress incontinence or leaking during effort or physical exercise. So this is often something people experience when they cough or sneeze or are active. A lot of times this is mostly females. The other big category is what we call urge incontinence, or leaking that's associated with a desire to avoid or to urinate. And this is what people experience when they say, "Oh, I can't get to the bathroom in time," or they leak when the faucet gets turned on, or leak when they pull into the driveway. But people can have both types, and when they have both it's called mixed incontinence. And then there are two other categories, one is nocturnal enuresis or loss of urine during sleep, and then another big category is called continuous incontinence where people have continuous loss of urine, this is often from something like an anatomic abnormality, like people can't urinate or they have something like a fistula.

Deborah Howell (Host): I see. So what are some of the signs and symptoms that you may be incontinent or borderline incontinent?

Leah Nakamura, MD: People who are incontinent, they begin to notice, a lot of times it's the females who may notice, "Oh, you know, I have a hard time making it to the bathroom in time," or they find it's more difficult to hold back their urine when they have an urge, or they notice that "Oh, when I exercise really hard, I have a tiny bit of leakage," or when they start coughing or have a bad cold, they notice, "Oh, there's a little bit of leakage." So that's some of the signs that people may notice early on. Of course, later in the game it gets worse and worse.

Deborah Howell (Host): Okay, so let's talk about the treatment. What are some of the best treatment options for stress and urge incontinence?

Leah Nakamura, MD: We'll break it down into the two categories as you said. So for stress incontinence, when people first begin having symptoms, and when the stress incontinence might be minor, they can do things like actually losing weight helps to treat stress incontinence, and performing Kegel exercises or those pelvic floor exercises. This also helps to treat it - something people can do on their own. But when it persists, it may require surgery to treat, and one of the gold standards that are pre-performed for surgical treatment are things like slings, and these can be made of various materials like mesh or using your own tissue which is called an autologous fascial sling, or even using cadaveric or porcine tissue. And then there are other surgeries that can be done like needle suspensions and injectable treatments for stress incontinence.

Deborah Howell (Host): And how effective are these surgeries?

Leah Nakamura, MD: The surgeries are very effective. Depending on the sling itself, the effectiveness of it runs anywhere between 80 to 90%, out to 10 years, so they're very, very effective and successful. It's just they do have their share of risks, so it's important to have a good discussion with your physician before embarking on going through surgery.

Deborah Howell (Host): Sure.

Leah Nakamura, MD: And then for urge incontinence, oftentimes we start people with behavioral things, so again, not heading straight to an intervention but doing things like not drinking an excessive amount of fluid and cutting back on bladder irritants like caffeine and teas and sodas, and then stopping fluids two hours before going to bed. And then just kind of making sure you have good bladder hygiene, going to the bathroom, not waiting to the last minute, doing timed voiding, going around the clock about every two hours. And if these things still are not effective, then we give patients things like medications. There are various different types of medications and classes of medications. And if those still are not working, then we can even inject Botox into the bladder.

Deborah Howell (Host): Oh, wow.

Leah Nakamura, MD: Yeah, yeah, it's one of the newer therapies which is very effective, and there's also nerve stimulation that helps with the overactivity.

Deborah Howell (Host): Now, let's talk about that for a second. Botox relaxes muscles. You would think it would have the opposite effect that you're looking for.

Leah Nakamura, MD: No, so in this case, that's exactly what we want because what happens when patients have urge incontinence or an overactive bladder, their bladder muscle is contracting too much. So it's almost like a spasm. And so what you want to do is relax it, and so that's why the Botox comes into play and does exactly what it does for the face to get rid of the wrinkles, it smooths out the bladder and helps to relax it.

Deborah Howell (Host): Wow. Incredible. I suppose there are some risk factors if incontinence goes untreated for a prolonged period of time?

Leah Nakamura, MD: You know, when incontinence goes untreated, it may continue to just get worse over time. And when that happens, patients experience more and more effects on their quality of life. You know, they have to wear more pads, they may have more accidents, they can get skin breakdown and irritation from wearing the pads or the wet clothing. They may be prone to other things like certain types of infections as well, like urinary tract infections or vaginal infections or skin infections. So those are the big things, but this is more of a quality-of-life issue rather than a life-threatening condition.

Deborah Howell (Host): I want to go back to something you said about frequency of going to the bathroom, about every two hours. A good thing, not a good thing?

Leah Nakamura, MD: It is a good thing. When people have incontinence or leaking, we want patients to go around the clock so that they empty their bladder before the accident happens. So that's why we encourage people who have these accidents to try to empty their bladder before they reach a point where it's too late and they have that accident.

Deborah Howell (Host): Does incontinence have anything to do with partially emptying your bladder and not being able to fully empty the bladder every time you go?

Leah Nakamura, MD: Absolutely. So when patients have overflow incontinence, they could be in retention and not emptying. So it's like a cup that's almost full to the brim. So you keep on adding to the cup and they'll spill over. So yes, if people are not emptying adequately, they're more likely to leak. Again, with the whole cup kind of analogy, it's easier to tip over and spill when it's fuller. So that absolutely is a component of the incontinence and risk for incontinence.

Deborah Howell (Host): When people come to you, do they have a certain shame factor?

Leah Nakamura, MD: Yes, they do, of course. Nobody wants to admit or talk about how leaking is affecting their lives or what they have to go through. But when they do come to see me, either I can either they come for a different reason and we eventually tease out what's going on with them, or they come because they're so miserable that it's really affecting their lives that they're ready to talk about it and ready to do something. But I think the main message is that people can start off earlier too and do more behavioral and non-surgical, non-invasive types of treatments for incontinence before we have to head to something like surgery. So there are several different options to treat the condition.

Deborah Howell (Host): You have sort of a dual role then, as almost a counselor-physician.

Leah Nakamura, MD: Absolutely. I think every physician does. I mean, we have a duty to counsel patients on several different things, and I think every condition is multifactorial as well, and so it's our job to counsel patients and make sure that we're doing things for their optimal quality of life, and not doing things just for medical purposes or like... it's all about talking with the patient and making decisions with them to get the best outcome for them.

Deborah Howell (Host): Absolutely. Run me through the Botox procedure. If I'm a person, a woman of 45 years of age, and I have incontinence, I come to you, and you say, well, for you, Botox is an option. What's the procedure?

Leah Nakamura, MD: So the procedure is actually fairly simple. It's done just in the office. We put a tiny camera into the bladder through the urethra, and then through that camera, we perform about 20 injections of the medicine throughout the bladder wall after numbing up the bladder with lidocaine. So the whole procedure itself takes just a few minutes to perform. People are fairly comfortable. But there are risk factors afterward. You know, the biggest risk factor with the Botox injection is not being able to urinate after because sometimes the bladder's too weak and can't contract and can't empty. And then there are other smaller risk factors like developing infections, bleeding from just the injection sites, that sort of thing.

Deborah Howell (Host): And then I suppose it's a little difficult to gauge, as the Botox wears off...

Leah Nakamura, MD: That's correct. So if it's effective, it usually takes about a week before people start noticing a difference. And if it's successful, it can last anywhere between 3 months to up to a year, average about 6 to 9 months. And then people notice that their symptoms are starting to return, which would mean they would need a repeat Botox injection at that point.

Deborah Howell (Host): Sure, sure. Okay. This has been really informative. I just want to thank you so much for your time and for your compassion for people suffering from incontinence.

Leah Nakamura, MD: Absolutely, I think people shouldn't be afraid to seek help and seek attention for this, and there's many different treatment options that are available and we can definitely help to make a difference in their quality of life.

Deborah Howell (Host): So it's a better day for patients with incontinence for sure.

Leah Nakamura, MD: That's great. Thank you for having me.

Deborah Howell (Host): And thank you so much, Dr. Nakamura, for spending some time with us this afternoon. It's been great to have you on the program and if you’d like to listen to a podcast or for more info, please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell, join us again next time as we explore another Weekly Dose of Wellness, brought to you by MemorialCare Health System. Have a fantastic day.