The Low Down On Incontinence

I’m back today with Dr. Tanaz Ferzandi to talk about incontinence. A word often mentioned jokingly but which describes a condition which is most certainly not a joke. I was eager to learn more about this topic as after having 3 kids I can no longer jump on the trampoline!

Dr. Ferzandi is the Service Line Chief of Obstetrics & Gynecology at Keck Hospital, the Director of the Division of Urogynecology and Pelvic Reconstructive Surgery, Associate Professor of Obstetrics and Gynecology, and the Associate Fellowship Director for Urogynecology at USC Keck School of Medicine. 

Be sure to check out last week’s interview with Dr. Ferzandi regarding uterine prolapse if you missed it.

Karyn: To make sure everyone is on the same page, what is incontinence?

Dr. Ferzandi: Incontinence is involuntary leakage of urine. The medical world further breaks down incontinence into stress incontinence and urge & frequency incontinence for most cases we see.   

Stress incontinence is literally stress on the bladder. We always have a little bit of urine in our bladder. This is normally held in by a certain amount of resistance in our pelvic floor and urethra. When this resistance weakens you can get leakage.

Stress on the bladder is anything which might cause the mechanisms of support to fail and urine to leak as a result. Regular actions which might cause stress include coughing, sneezing, jumping exercises, and even potentially intercourse.

The second form of incontinence is urge and/or frequency incontinence.  The first refers to the sudden urge to void while the second refers to the need to go to the bathroom very often.  Frequency incontinence is often the result of someone who consumes too much liquid.

Urgency incontinence results when your bladder doesn’t allow itself to fill well enough before signaling to your brain you need to go to the bathroom. This is also referred to as overactive bladder. Some people have overactive bladder dry, which means they have urgency but they don’t leak. Others have overactive bladder wet. They have urgency and they also sometimes leak getting to the bathroom or just accidentally leak.

People who have this type of incontinence feel an urgent need to go pee without any warning. Imagine you are doing the dishes, suddenly you have an urge to urinate and you are not sure you can make it to the bathroom. You really have to go and you just hope you can get your undies off in time. This is often described as the “key in the door” problem.  Ironically commercials have desensitized this topic and people know to seek help rather than live with it (patients recall the “gotta go, gotta go” commercial jingle).

Many women suffer from both urgency and frequency incontinence. There are also less common conditions which are secondary to diseases processes but we don’t see these routinely.

Karyn: Who is most susceptible to incontinence?

Dr. Ferzandi: We know stress and urge incontinence is something most women will experience at some point in their lives. It tends to be an issue which surfaces in midlife, after age 40. However, I am seeing more women in their 30s with it. Most women seem to be comfortable dealing with minor or infrequent stress incontinence. They are used to wearing a pad (during their menses or for vaginal discharge) or just choose to avoid certain activities.

Changes to the pelvic floor from pregnancy and delivery is also a common cause of stress incontinence, both during and after pregnancy. However, I don’t like to intervene until someone is at least a year postpartum and/or done with childbearing. I like to wait and see where their hormones stabilize.

Other common factors which can make someone susceptible to incontinence are obesity and having a chronic cough.  Eventually, age becomes the key factor.

Karyn: If someone has incontinence when should they seek help and what can be done about it?

Dr. Ferzandi: Typically, someone seeks help when their incontinence becomes a quality-of-life issue.

Having said that, I often see daughters bringing their moms in, saying “Mom, you can’t keep living like this.” I think the younger generation feels more comfortable talking about female health issues. In the previous generations, it just wasn’t something you talked about. In my older patients I often hear, “Oh, it’s just age and I have to live with this.”  Women tend to often put the health of their families and others above their own. 

Incontinence is not going to get better on its own. It is possible it will stay the same or more likely it will get worse. But it won’t correct itself without intervention. Time is not our friend in this case, as tissues in the pelvic floor area weaken with age.

Stress Incontinence

 Stress incontinence is easy to treat. Kegels can help, there are specific pessaries (although not as helpful), and there is a minimally invasive surgery with a very high cure rate and high satisfaction rates

Pelvic floor therapy and/or Kegel exercises, if done correctly can be very helpful and are a great first step. If you can improve your symptoms enough so they no longer impact your quality of life, it is all some women need and want.

The most common procedure is the mid-urethral sling which has been around for over 20 years. Essentially, we put a tiny piece of mesh tape underneath the urethra. It scars into place which recreates the resistance someone is lacking when they have stress incontinence. It is an easy and straightforward outpatient surgery. You are done and on your way home in less than 30 minutes.

The mid-urethra sling is one of the most studied products in medicine, is very effective, and has very low complication rates. Your readers should know the sling is a great, safe solution in a skilled surgeon’s hands.

Urgency & Frequency Incontinence

Unlike stress incontinence, the impact of an overactive bladder on quality of life can be more significant. And most women have very little tolerance for the situation.

 The first step is fluid management and retraining the bladder. We help manage what fluids patients drink and how much fluid they drink. Then we help get them into a voiding habit which is healthy for the bladder.

I start with having patients bring me a bladder diary. This gives me a baseline of what is happening with their daily habits. It tells me how much they drink, how often they go to the bathroom, and how much they urinate. I use this information to guide their specific treatment plan, which outlines how often to go to the bathroom and how much to drink.

A common misconception is people think I am going to take away their fluids. But actually I want them to drink a steady amount and in a steady state.  We advise limiting caffeine and alcohol, as these are irritants and can cause overactive bladder.

Physical therapy is often used in conjunction with behavior modification. If this approach does not correct the situation, we can move on to medications and minor procedures for treatment.  

We can inject Botox into the bladder to calm down the muscles. There is also a stimulator we use to stimulate a nerve near the ankle which feeds up into the bladder. It is not as effective a treatment as other options, but for some patients it’s all they need.  Another option is a small stimulator we place in the upper side of the buttocks.  This device directly stimulates the nerves of the bladder.  My patients refer to it as their “bladder pacemaker”!

One note of caution, we must be mindful of medications with older patients as some of these medications can have negative cognitive side effects.

Karyn: Do hormone changes during perimenopause and menopause play a role?

Dr. Ferzandi: We know there are estrogen receptors at the base of the bladder which play some role in incontinence. However, it is not the case where if someone is suffering from incontinence, giving them estrogen is going to cure it.

If patients have severe atrophy of the vaginal tissues and the tissues have become frail, vaginal estrogen cream can help address the atrophy. We believe this can lead to some improvement in bladder symptoms, but it's not in lieu of taking the other steps we have discussed.

I also want to mention there is no causative link between vaginal estrogen cream and breast cancer. So, if a woman’s symptoms are all in the pelvic region, we can use vaginal estrogen cream. Which is great as it can bring a lot of local relief.

Parting Thought

I hope you have enjoyed these 2 conversations with Dr. Tanaz Ferzandi. You can connect with her at ferzandi@usc.edu  or via the Keck website: Tanaz R. Ferzandi, MD - Female Pelvic Medicine, Urogynecology | Keck Medicine of USC.

See you next week…