Female Bladder Leakage: Solutions to Get Control‎ | UCLA Obstetrics & Gynecology

Good morning, good afternoon or even good night, depending on where you are coming from. Welcome, my name is Dr. Christopher Tarnay and I am the chief of uro

gynecology

here at UCLA in the department of

obstetrics

and

gynecology

and today we are going to talk about

female

bladder

leakage

and we will focus on

solutions

to manage this very challenging problem for women , so during the webinar feel free to ask questions we have here, he is monitoring our Twitter account. use the hashtag UCLA MD chat UCLA MD chat or you can just put comment comments on Facebook and during the webinar we'll follow along and at the end I'll address some questions.

Well, let me start with some geography. I know where this could be is the Blue Ridge Mountains and it is a northern part of Virginia. I had the opportunity as a medical student at Georgetown when I was in DC to go visit them and one thing I didn't know at the time was that the Blue Ridge Mountains and the vagina share something in common. I hope I have your attention now and what they have in common is a similar topography. Women have estrogen and the estrogen in the vaginal area creates a thickening and that thickening creates a little sagging of the tissue. creating small folds called folds and these folds are very important because they create a functional impact on the vagina.

It has folds to allow lubricants and secretions. These folds also allow them to stretch and the folds are thus peaks and valleys and that stretching allows function during childbirth. during sex and the problem later, as estrogen decreases during menopause or estrogen decreases during breastfeeding or after childbirth, is that that elasticity disappears, the tissues of the vagina can flatten and those wrinkles flatten , they become thinner and drier and that can create challenges during this transition. Sometimes with the inner core also the

control

of the

bladder

and that is what I want to talk to you about today the

female

bladder leak is urinary incontinence what is urinary incontinence the involuntary loss of urine or simply urinating or losing urine when you do not want one of The most important questions that patients ask me when they come to the office is that they feel a little isolated, they say, this is the only thing that happens to me is this urinary incontinence.

Am I the only one who has it? It is important that you know that it is extremely common. Currently, two in three women are at risk of urinary incontinence in their lifetime, although incontinence increases as one ages, it can actually occur at any time during life and women can experience symptoms at any time. . It affects more than 200 million people worldwide and around the world. In the United States alone, at least 25 million, and of those 25 million, between 9 and 13 million women have bothersome or severe symptoms, how about some more data? Urinary incontinence is underdiagnosed, underreported, and as I mentioned, it increases as we age.

It is primarily a female problem since more than two-thirds of people who have urinary incontinence are women. There was a study that looked at a random sample of forty-five thousand different households and during that survey, 35.37 percent of women reported incontinence only in the last two months in the elderly. More than 70 percent have complaints of urinary incontinence and this alone may be the reason why seniors must move into a different living situation than a skilled nursing facility or assisted living just to manage incontinence. This graph shows that as we age, urinary incontinence becomes more common among young women in their 20s and 30s, about 30% among middle-aged women in their 40s and 50s, 40% and in their mid-teens. 60 65 After menopause, more than half of women will suffer from urinary incontinence.

Another question that I hear a lot is: is it normal to leak a little urine or is it just a little urine? That's normal, right, no, it's not normal. The leak is common but it's not normal and it's very important to understand that women who suffer from Incontinence can be done very gradually in an insidious way because it is a gradual and insidious problem, so often women do not believe it is a medical condition and do not mention it to their doctors or medical providers, this causes delays in women who seek care and it is very important for us to communicate and you to communicate with your friends and so that you know that one does not have to live with urinary incontinence without seeking treatment, it is important, although urinary incontinence is not life-threatening, it is what I call a threat to quality of life and can affect a woman's life in many different ways. physical domains reduce physical activity because they do not want to filter psychological they do not want to feel old they are worried about the smell they lose self-esteem higher rates of depression in women with urinary incontinence reduce their interaction in social events a woman told me I never go anywhere without being nearby from my boyfriend John I mean she was always always near the bathroom she felt chained to it wearing padded underwear is very expensive and problematic some women say they pack two suitcases when they travel one for their clothes one for their occupational sanitary pads can they meet the women who are working?

This can cause a reduction in work attendance and avoidance of intimacy. Okay, women with incontinence offer to suffer in silence and this is part of the dialogue we have. The survey of women who want to change suggests that women don't like to talk about this problem even with their provider and, honestly, doctors aren't that good at it either, we don't do a great job asking patients about this problem between our four doctors in a survey when after their visits during their annual exam the doctor did not even ask or examine them about incontinence problems, this creates a delay that women will often wait more than six years before living with the condition before to even mention it.

We need to change the way we look at incontinence and get it out of the shadows, get it out of the bathroom and start to recognize it, times are changing and the ways and one of the avenues are the pharmaceutical companies, the companies that are selling medicines, medicines and treatments, They will target consumer marketing. This ad was during last year's Super Bowl for a new drug. You see this in print ads. Advertisements in the media. Playtex has joined the action. They have a product called Impressa. which is designed to help prevent urinary

leakage

works by inserting it into the vagina similar to a tampon to compress the urethra and prevent leakage.

We have the support of celebrities who are now coming to the forefront talking openly about female bladder leakage and urinary incontinence and offering ways for women to gain

control

, but most importantly I believe this will help close the huge gap for women to gain control. We can start having a conversation, so there are two main types of incontinence, stress urinary incontinence or what I would call stress urine loss, so this is not just any time. losing urine with coughing, laughing, sneezing or doing physical activity hey doctor, I don't jump, I no longer jump on the trampoline with my daughter because it causes leaks, I wanted to play hopscotch, no, no, I can't do it. which with my daughter or sons is common after pregnancy, particularly pregnancy that results in a vaginal birth, so stress incontinence is basically increased pressure in the bladder that exceeds urethral resistance, coughing, laughing, sneezing, all can create urinary loss due to pressure and lack of support. below the urethra, the other type of incontinence is urge urinary incontinence or I think this is the symptom when patients say I have to go, I have to go, I can't go to the bathroom, otherwise it is called overactive bladder, the Overactive bladder has to do with women. i have this overwhelming inability to resist the sensation of urinating it has to do with early and inappropriate bladder signaling normally we should be able to feel the sensation of our bladder if we are out of the house where I say it no now I'm inside the cinema I'm in the store I'll wait until you get home overactive bladder is a problem when you cannot suppress that sensation and either due to increased sensation or muscle contractility, it squeezes the bladder involuntarily causing such urgent urinary loss.

Continence is the loss of urine with a strong urge, it is also characterized by urinary frequency and urgency. Often, women cannot hold their bladder for more than two hours at a time, feel like they have to go, and may leak just before reaching the bathroom. Urge urinary continence sometimes causes patients to wake up at night. About once is normal, but anyone who wakes up 2, 3, 4, or even 5 times a night to urinate is a classic overactive bladder. One problem that patients often convey is that Dr. Just when I get home, I park my car in the driveway where I am walking down the hallway toward the front door.

I put my key in the door. I immediately dropped my bags, ran to the bathroom and when I asked them, they told me. Wow, yes, that's me, it's called lock key syndrome, so who understands you is close to the content: women are twice as likely as men. That sounds terribly unfair. Why is that anatomy and risk factors fast? Anatomy trip we will talk a little about the physiology of the kidneys. It filters the blood, the waste products from that blood filtration end up in the kidneys and deliver it to the bladder through tubes called ureters. The bladder is a storage organ and should store urine comfortably and painlessly until you are ready to urinate and then once. you are ready to urinate it came out through a tube called the urethra one of the reasons why women are particularly bothered with this problem is physics they have a short urethra a very short tube men generally have a longer tube as a urethra increases resistance women with a shorter tube less resistance capacity and therefore anything that can cause damage to the anatomy can trigger urinary incontinence such as vaginal birth or occupational exposures, we will talk about what the risk factors are, age, since when we get older we talk about estrogen as estrogen.

It reverses the change in vaginal tissues, leading women to become susceptible to overactive bladder and stress urinary incontinence. What this changes in the lining of the bladder. Pregnancy Pregnancy itself contributes somewhat to the weakening of the bladder. If the pregnancy results in a vaginal birth, the more vaginal births, the greater the risk of urinary incontinence. conditions with chronic repetitive straining cough asthma chronic constipation smoking can contribute to unary incontinence activities women with occupational exposure there was a study in Sweden that looked at women who worked in nursing homes transferring patients lifting Gurney, those women when compared to aged controls equivalent had higher rates of pelvic floor problems, including urinary incontinence, obesity, the more weight you are, especially if you are over 30, the more pressure on the bladder, the more pressure and stretching towards the pelvic floor, and genetics, some people They are just prone to it and this is a big area of ​​research and attempt.

To understand which women might be at risk, here is a slide that demonstrates that the older you get, the more common the problem is. I talked a little about pregnancy. This is a cartoon just to show the impact on the various pelvic floor structures during the act. of childbirth here is the bladder here is the vaginal canal here is the rectum when the fetal head passes through this space it puts pressure here it puts pressure on the rectum it can cause alteration of the connective tissue it can cause stretching of the pelvic floor muscles and all those the Compression can damage the bladder and its support, what are the treatments for urinary incontinence and does that depend on which set of symptoms are more bothersome or bothersome? it's stress urine leakage, it's urgency and frequency and sometimes it's both, and then if we have both, we try to focus on which issue is more problematic for the patient, so if it's stress incontinence , is it an urge incontinence or both types, the first best option for all types is pelvic floor muscle exercises, conservative, non-surgical and non-medical therapy, is the basis for all therapies a little about the exercises of the pelvic floor muscles, also known as Kegels, the pelvic floor extends from the pubic bone to the tail bone and between this area, as you know, in a woman, this is a side view, it is the bladder and the vagina. with the uterus and the rectum and the contraction of these muscles that allow compression and increased pressure around the outlets of these structures such as the urethra or the rectum and in this case we are trying to contract the pelvic floor to increase resistance to urination.

Contracting the pelvic floor can alsofeed back to the bladder and reduce the urge, called impulse suppression. Like I said, pelvic floor muscle exercises are the same as Kegel exercises, something patients are told to do all the time. One of the important critical features is that I have to acknowledge that there is good evidence from level one controlled trials evaluating muscle or pellet exercises and their impact on urinary incontinence and that it works about two-thirds of the time. It can be done alone or with the help of a sub-physiotherapist. Those who really train especially to take care of women's health problems can work with patients teaching them how to do them correctly, learning tips to identify the correct muscles is essential because when we ask patients to simply do Kegel exercises without any instruction, around two or thirds of the time you can't do it correctly, it's very easy for us to identify if I tell you to do a pushup and I want you two to strengthen your biceps muscle, it's very easy for us to see a biceps curl if I ask you to they do it.

In a Kegel exercise it is impossible to see or know if you are doing it correctly and this is where therapists can really help with that biological feedback, biofeedback, to help women learn how to do this skill properly, since anything takes practice. and commitment because if you stop, there is evidence to suggest that patients get an initial benefit but then stop doing their Kegels or their pelvic exercises. floor exercises incontinence can return is an excellent first option even with the benefits of Kegel exercises in the pelvis to strengthen sometimes in the long term it is not enough this is where we have to think about other issues such as surgery and good news en There are a lot of good minimally invasive options that we have available to help correct long-term urinary incontinence and I want to talk about the ones that we basically want, we want women to be able to run, jump and sneeze without pain.

I thought they were cool hashtags hashtag mommy issues and hashtag lack of knowledge okay so I mentioned slings let's talk about them for a moment what is a sling it's a 20 minute outpatient procedure 20 minutes at home same day - correct the Urinary incontinence has been around for over 20 years in its current Through a small incision surgery, a support is placed under the urethra to prevent loss of urine with straining, so this is a video. Here there is a spore support pressure that triggers urine loss. We need to do something to help support. We can use a sling.

It can be a small piece of material, either permanent or your own tissue, that we place provides that support and prevents urinary loss. It's very effective, very simple and this is what it looks like. It can be what we call retropubic and there are others that come out as we call it. trans obturator through the groin small piece of one centimeter wide below the urethra highly effective and with more than ten years of data more than 80 years improvement rates of care objectively two years long term seventy seventy years seventy percent more what else Do we have a laparoscopic surgery called birch?

It is also a same-day surgery that uses small incisions that support the bladder neck from above. Without implants. Without materials that increase volume. Volcanoes like collagen. Many and we use it as filling. Many women are used to seeing. celebrities with lip filler for collagen and the material we use is a similar type biological material where we place it right in the bladder neck here is an open bladder neck in which we place the bulking agent as if it were a collagen and increases resistance. by co-opting, co-opting the urinary outlet actually increases pressure and reduces urinary loss.

There are also some interesting new things at UCLA that were involved in the research and one of the most interesting areas is looking at essentially what a stem cell essentially extends to us. Cell-based therapy, which we call cell-based therapy, uses muscle cells, muscle progenitor cells, and we implant them into the urethra to restore function. The formal name is autologous muscle-derived cells and we are doing ongoing studies at UCLA right now. We take muscle cells from the patient's thigh, send them to a laboratory, grow them in culture. After a couple of months, we bring them back and do a procedure in the office to implant them near the urethra to give a new function to the toes of the patient. urethra without surgery no strange implants it is your own tissue and there are no incisions everything done in the office very exciting very new going back to the treatments like I said what we are going to do is move on to urgent incontinence pelvic floor exercises excellent first therapy for women with Overactive bladder diet and fluid modification becomes very critical for these types of patients and we put patients on what we call a bladder diet and it sounds a lot worse than it really is, but it means removing the triggers that could cause Bladder overactivity and here is a list. of just a few of them and what I would call the common suspects that could contribute to bladder overactivity caffeinated drinks alcoholic beverages carbonated drinks acidic juices can potentially cause bladder irritation, urgency and frequency spicy foods even chocolate sorry ladies , but movie These diet things can often give you a great idea of ​​what your bladder triggers are and then you have control over your bladder and it's about giving control back to patients.

What if Kegel exercises don't work? What if that bladder? The diet doesn't work, what else do we have? We have other things, medications, Botox neuromodulation and posterior tibial nerve stimulation, so medications have been around for a long time, you'll see them marketed directly to consumers and doctors may have told you about them before. but they are all designed to help reduce urinary urgency and frequency and incontinence episodes when compared to placebo, most of them have some benefit, sometimes it is mild and the main class are what we call anticholinergic medications and here are a list. with their trade names and all of these work in a similar way.

There is a more recent introduction which is what is called a beta 3 agonist that works with a slightly different mechanism and they all work quite well by reducing the urgency, frequency and episodes of incontinence. There is nothing free. walk there are some side effects anticholinergics most commonly are dry eyes dry mouth constipation and dizziness and beta 3 agonist headache joint pain dizziness blurred vision all of them usually mmm mild and not severe but they can be very annoying and sometimes the side effects They are more problematic than the condition they are trying to treat, so it is highly independent of each individual, but if used frequently enough, what else do we have for patients who do not do well with pelvic floor exercises, those who don't do well on the bladder diet and are still struggling, those who have tried medications and they didn't work, or tried medications and don't want to take them.

We have other options. How about Botox? Well, everyone is familiar with Botox being used for cosmetic reasons. In fact, we can use it in the bladder, it's an in-office procedure, we take a cystoscope and we look inside the bladder and we put the Botox in different places within the blood or using a small injection needle and when we look at the results, it reduces the urgency. In 60% of patients, the benefit lasts but is not permanent, so it usually only lasts about six months, so patients often need one or two treatments a year. The side effects are very low, but it is important to discuss them because sometimes Botox has such an effect.

It is good to relax the bladder muscle, which patients find difficult to empty completely, but this occurs in only 3 to 6 percent of patients. What about other therapies? Well, there is a therapy that we have been using for over 10 years called neural modulation. Placing a wire or a small wire directly on the nerves above the buttocks is for patients with severe refractive overactive bladder who did not do well with medications and is like using a pacemaker in the bladder when we place a small implantable pulse generator right in the back above the buttocks with a small wire that connects through small nerve roots in the sacrum and this greatly reduces the urgency and the frequency and the really nice thing about this is that we can evaluate patients with plaque before perform the implant with a temporary evaluation and for women. who have successful temporary leads placed when they get the eighty percent permanent reduction in urine leakage which is very exciting and without medication in its long life, the batteries last five to seven years and would only need to be replaced periodically On the other hand, the type of therapy that is a form of neuromodulation is stimulation of the posterior tibial nerve.

It's an in-office treatment that requires nothing more than a small acupuncture needle placed right in the ankle and we apply some gentle electrical stimulation via a small handheld battery. This little stimulation in the ankle. works the nerves that go to the sacral nerve roots to affect the bladder and reduces urgency requires a 30 minute session so you come to the office you sit with your clothes on with your book your iPad or your Kindle you have a 30 minute session after we put the acupuncture needle in and we do it for 12 weeks and we look at this data, it works as well as the medication, we are still not sure about the long term benefit as often patients need boosters maybe once a month or so , but that's very exciting for women who can't tolerate medications and don't want to go through the trouble of other therapies, so we summarize

solutions

to manage stress incontinence, pelvic floor muscle exercises, and changes in diet.

If one wants to do surgery, we have birch slings to increase volume, all with excellent data. Overactive bladder. Pelvic floor exercises. Kegel exercises. Medicines. Normal Asian botox or posterior tibial nerve stimulation. Well, I think that's all I have for you, but I would like to respond. a few questions and I think Cleve may have some for us okay the first question is about diet and then should I cut out all chocolate and alcohol and improve my lifestyle before deciding on surgery? I would say it is always wise to use all preservatives. therapies before all conservative there are four therapies before talking about surgery the draconian implementation of eliminating all chocolate and alcohol is a little harsh, but what I tell patients I tell them to think about it as to avoid allergies, take it out a few days and see.

Yes it makes a difference Yes caffeine Yes chocolate Yes alcohol is a real trigger You will notice a difference in the function of your bladder after just two or three days of eliminating it from your diet and then it will all be a matter of control because if you notice that your bladder yes It is better that if you have to go out that day you skip the morning latte, but if you are at home and close to a bathroom, no problem. Alright, another question about neuromodulation. Neuromodulation technique ten. What are the pros and cons? Is it just as effective? like mesh, okay, so that's a good question.

I'm going to go back a slide just to differentiate when we talk about neuromodulation it's for patients with overactive bladder it's the type of incontinence with urgency and frequency the advantages of neuromodulation is that it doesn't require medication it's a long term treatment once you get it and it works , that's it, you have to think about it for five years, it just requires maintenance programming that is very simple to do and easy to teach, and its complication rates are pretty safe with neuromodulation. are very low, about 9% of the time patients have to have the implant removed, either because it doesn't work or sometimes it can bother patients because it sits or presses on the skin in an uncomfortable way.

The question is whether it is just as effective. as a mesh, we don't use any type of mesh for our overactive bladder slings which would be for stress incontinence, so they would actually be treating two different things. I hope that answers your question well, when do you know if I have to have a mesh, so I'm going to go to that question right now because I actually have a question prepared for you, so let's skip it for a second and come back to mesh. is safe and when you know you should have it mesh is safe and should be used for patients who have stress urinary incontinence toslings.

What you've heard about and what the FDA has intervened in is the use of mesh for prolapse that we haven't talked about today, that's bladder prolapse, vaginal prolapse, when we apply mesh in those settings, complication rates are, in my opinion, unacceptably high and I do not recommend anyone get transvaginal mesh for their prolapse, however we have great evidence of safety and effects, the effectiveness of slings and therefore the use of mesh for slings. I think it's a reasonable idea because the safety and effectiveness of slings are well established in clinical trials that followed patients for over a year and since 2008 the FDA has consistently differentiated between transvaginal mesh for prolapse and transvaginal mesh for sui we have good There is no evidence that mesh slings can help with stress incontinence, there is no good evidence that it is safe for patients with transvaginal mesh for prolapse, that being said, we also have non-mesh slings, you can use your own. own tissue, so patients who work and who are wary of it and I would definitely recommend that you talk to your doctor before considering something like this to talk about using your own tissue and as a viable option, this is just the law , since you This is where all the patients, when they come, have seen this online and on TV, okay, but any other questions, I think I'll go to the Kegel question because it generated a lot of interest before.

I'm going to come back here so one important thing I would like to leave you with is how do I do a Kegel well so pelvic floor muscle exercises will only help if they are done correctly and there are many ways to learn and I will show you one way and I have a short cartoon that's from Big Bump TV, so usually the best thing to do is do it when you're not distracted, do it while you're lying down or sitting up, coming back here's your pelvis. The floor here is the rectum, the vagina and the first thing you should focus on is the back, think as if you are holding in gas and you don't want to expel it.

The next thing you should practice is thinking as if you want to do it. contract like you don't want to urinate and then do both together and hold it for 3 5 even 10 seconds once you learn that skill do 15 contractions for 1 set 15 contractions holding it for 5 to 10 seconds relaxing and repeating 3 sets a day every day, that's a good Kegel exercise routine. I think that's all we have for now. One more question.one more question Cleve has it right, one more question about leakage after urinating, what category does it fall into and what is the best treatment for that, so the last thing we'll talk about is what is this guy asking about and what would we call leakage or dribbling after urination, many women will feel empty, stand up and leak some urine, which often reflects incomplete emptying of the bladder and may be due to poor anatomy, so patients You may have a sagging bladder or a sagging urethra, which actually contributes to a small amount of urine collecting near the opening that is not evacuated while sitting and then once you stand up. , usually a small amount of urine can leak and that can be solved. with a more appropriate evaluation in the office, very good, thank you for registering today and I appreciate your questions.