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BackTable / OBGYN / Podcast / Transcript #61
Podcast Transcript: Evaluating Female Urinary Incontinence: Essential Steps for the Generalist
with Dr. Sarah Boyles
With contemporary treatment options, your female patients don’t have to live with urinary incontinence! In this crossover episode of BackTable Urology and OBGYN, host Dr. Suzette Sutherland from University of Washington interviews Dr. Sarah Boyles, a urogynecologist at The Oregon Clinic, regarding female urinary incontinence, its diagnostic criteria, and various treatment options to help improve quality of life in the incontinence patient. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Scope of Female Urinary Incontinence: How Common Is It?
(2) Identifying the Types of Urinary Incontinence: Stress, Urgency & Mixed
(3) Key Diagnostic Steps for Evaluating Urinary Incontinence
(4) Streamlining Incontinence Diagnosis: Avoiding Unnecessary Tests
(5) Initial Treatment Approaches for Urinary Incontinence
(6) The Effectiveness of Intravaginal Devices in Urinary Incontinence Treatment
(7) Weight Loss as Part of the Incontinence Treatment Plan
(8) Choosing the Right Urinary Incontinence Treatment Device: Cost, Comfort & Effectiveness
(9) Stress Urinary Incontinence: Urethral Bulking, Surgery & Specialist Referrals
(10) Urgency Urinary Incontinence: Medication, Neuromodulation & Emerging Therapies
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[Dr. Suzette Sutherland]
Hello, and welcome once again to Backtable Podcast. This is a BackTable Urology and GYN Podcast today. I'm your host again today, Dr. Suzette Sutherland, and I'm excited to have Dr. Sarah Boyles as our guest for this special episode entitled, What Every General OB-GYN and General Urologist Should Know About Female Urinary Incontinence. Good morning, Dr. Boyles.
[Dr. Sarah Boyles]
Good morning. Thank you so much for having me.
[Dr. Suzette Sutherland]
Thanks for agreeing to do this for us. First, let me tell you a little bit more about Dr. Sarah Boyles. She is a urogynecologist who practices in Oregon at the Oregon Clinic. That's in Portland, Oregon. She is part of the first cohort of practitioners who got sub-specialized in the area of female pelvic medicine and reconstructive surgery, which means that she is specialized in doing work in women's pelvic health such as incontinence, prolapse, and so on and so forth.
I too, am one of those initial cohorts. I know when that was. That was in 2013. That's been many years just specializing in this area of women's pelvic health. We're really excited to have her here today with all of our expertise to help talk to us today about women's incontinence. A little bit more about her. She started the womensbladderdoctor.com during COVID. Sarah, why don't you tell us a little bit more about that?
[Dr. Sarah Boyles]
During COVID, my life changed a lot like a lot of other people, and I found that I had a little bit of additional time. One of the things that I've always found is that women are really lacking information in incontinence and not sure where to go. I created this website. It initially started as a blog, and then it advanced to having some courses and some masterclasses to help educate women on incontinence, why it happens, the different causes, things you can do at home, and then the different treatments just to help women figure out what their next steps are.
[Dr. Suzette Sutherland]
If you look her up online, it'll also say she's CEO of what's called The Women's Bladder Doctor LLC.That's what this website is involved in, this very wonderful educational resource. I've had a chance to look at some of this information that's on there too, and also started a bit of a podcast during that time called While You Wait... That's really a wonderful idea. Tell us a little bit more about that.
[Dr. Sarah Boyles]
More recently, the waits to come see me have gotten to be pretty long for a million different reasons. I was speaking to some of my colleagues who were primary care doctors and some of my big referring physicians, and they said, "What can we do for our patients while they're waiting?" That's how my podcast was born. It is to help women while they're waiting to come see me, to help them get started.
I'm really proud of the educational content that's out there, but it also helps me because it means that sometimes women will come see me and they'll have already done a voiding dairy or have already worked on eliminating bladder irritants or doing some pelvic floor muscle training. It's been really beneficial for me too.
(1) The Scope of Female Urinary Incontinence: How Common Is It?
[Dr. Suzette Sutherland]
Great. Why don't we just jump in on female urinary incontinence? How big of a problem do you really think this is in the general population?
[Dr. Sarah Boyles]
It's a huge problem. There have been some recent studies that have queried the American population and about 60% of women leak at some point. 30% of women leak regularly, but it's not something that we talk about because there's so much shame associated with it. So many women think that it is normal. While it is common, I would say it's not normal. It's a big problem.
It is definitely a bigger problem in older populations. It becomes more common as we age. There are lots of young women who suffer from incontinence as well. About 10% of the population will leak their entire lives. It's a big problem that we're not addressing and talking about.
[Dr. Suzette Sutherland]
Since it's not cancer or life-threatening, oftentimes it does get ignored. We see that all the time. Patients come in and you're just flabbergasted that they've been dealing with this for 20 years already. You think, "Gosh, why hadn't you come in sooner? We could have allowed you to jump on the trampoline with your kids when they were young. Now your knees hurt so you can't jump on that trampoline." There are a lot of statistics too in the older patients that look at the number of falls and fractures at night with how many times people get up to go to the bathroom at night. We know that it really definitely can be threatening to people's quality of life for sure.
[Dr. Sarah Boyles]
I think just like you said, medically, it is not considered to be as important of a problem as cancer or heart disease. That's definitely true. It has such a negative impact on quality of life. It impacts body image. It impacts self-esteem. It impacts mental health, sexual relationships, personal relationships. I think in order to age gracefully, we need to be active and social. This is something that prohibits that. It's a very important thing to address. The data on falls with urgency incontinence is pretty alarming and pretty dramatic.
(2) Identifying the Types of Urinary Incontinence: Stress, Urgency & Mixed
[Dr. Suzette Sutherland]
Well said. It is a quality of life issue. That's how I talk to patients as well. Then we really emphasize what quality of life do you want? This is impacting it. Well said. When we talk about trying to evaluate a woman for urinary incontinence, we know there are a number of reasons why women leak. Not one woman's incontinence is the same as another woman's incontinence.
The reason they leak, then that totally dictates what the right treatment options are. Can you tell us a little bit more about what are the main types that we need to be thinking about so we can diagnose the woman correctly?
[Dr. Sarah Boyles]
When patients come to the office, they're just upset that they're leaking. They're not thinking about why they're leaking or the pathophysiology behind it. It's really up to us to figure that out. In women, there are four main types of leaking. There's stress urinary incontinence, which is leaking with a Valsalva maneuver. Coughing, sneezing, exercise will do it. Laughing. I will frequently tell my patients they should stop laughing, but no one ever takes me up on that. It should be a discrete leak. That leak should only happen while you're coughing or while you're running. It shouldn't be a big leak that continues afterwards.
There's urgency urinary incontinence, which is part of the overactive bladder spectrum. That's when women are going to the bathroom frequently. They have a strong urge to get there. They're worried that they can't get there on time. There can be associated leaking with that as well. Sometimes that does include nocturia, going to the bathroom frequently at night. There's mixed urinary incontinence, which is both. You can leak for two reasons. Mixed urinary incontinence is actually the second most common type of leaking.
Urgency urinary incontinence is the third. Then the last is overflow incontinence, where you're not emptying well. There are a couple of other more rare reasons why women will leak like fistulas, but they're pretty uncommon. Then there's usually other cues in the history that would make you think of a fistula. Pretty rare.
[Dr. Suzette Sutherland]
I'm sure you feel the same. One of the most difficult things is when a woman really has mixed incontinence. A combination of both stress and urge because they have two reasons why they're leaking that are very different reasons that require different thought processes about how to fix those and educating the woman about that is really important.
[Dr. Sarah Boyles]
I definitely agree with that. I think that expectation setting is so important because a patient only cares that they're leaking and they want to stop leaking. If you fix half the leaking, so the stress incontinence and not the urgency incontinence, that's frequently perceived as a failure because they see it as continuing to leak. Really discussing why they're leaking, making sure people understand that becomes really important. They're part of the treatment process and they understand the successes that they're having and they're not disappointed. They understand that you're going to need two different treatments. We're going to start with one and then we'll get to the second one after that.
[Dr. Suzette Sutherland]
That is such an important point. I see women all the time who come in and had a well-placed midurethral sling. It's working for their stress incontinence. They're still leaking because they have OAB urgency incontinence and they say the sling never worked. That's their perception. Educating them about what type of treatment works for what type of problem. You have to educate them in order to be able to assess the true efficacy of your interventions.
[Dr. Sarah Boyles]
I definitely agree with that. That is such a common thing to see where someone comes in and they say, "Oh, the sling failed. It never worked," and it's working beautifully. We just have to focus on something else. Those are important conversations to have with people. It's always important when you go into surgery to know what you're going to get and what you might not get and what additional work we have to do afterwards.
[Dr. Suzette Sutherland]
Absolutely. What's left over so that you can talk to the patient about that and say, "Remember, you're still going to have X, Y, and Z, and we're going to work on that, but that's not what this intervention is meant to do."
[Dr. Sarah Boyles]
I'm sure you do the same thing. I think it's always really important to under-promise and over-deliver. You want to tell people they're going to leak a little bit and then if they don't leak at all, they're pleasantly surprised. If you have more work to do, they're on board with it.
(3) Key Diagnostic Steps for Evaluating Urinary Incontinence
[Dr. Suzette Sutherland]
Yes. Along the same lines about trying to determine what's going on and overall with their voiding pattern and so on and so forth, what are the minimum diagnostic things that one should do to work up a woman with incontinence? I think most of the time we're really able to talk to the woman. If you ask the right questions in the right way, you pretty much can figure out what's going on, but there are a few key diagnostic things that everyone should do before initiating intervention. Let's talk about those.
[Dr. Sarah Boyles]
Like all things in medicine, I think the most important thing is the history. Incontinence is usually a very benign problem. You want to make sure that the patient doesn't have any neurologic symptoms, that there isn't anything else going on that might point you in a different direction. I think certain patients who have had extensive pelvic surgeries or who have failed incontinence procedures or who have had pelvic radiation, those patients fall into a special category and deserve more attention and a more in-depth workup.
In general, you're assessing the history, you're getting their symptoms, you're figuring out why they leak, and then you do your physical exam. The additional diagnostic things that you really want to get is you always want to get a urinalysis and you can definitely assess urinary incontinence on a virtual visit, but even if you do a virtual visit, you have to get the UA. What you're really looking for is you're looking for infection and you're looking for blood. Those are the big things because hematuria is not something that we want to miss and there is an overlap in overactive bladder symptoms and then symptoms that might be related to something with more pathology.
[Dr. Suzette Sutherland]
Yes, absolutely. If there's anything abnormal in the bladder, it's going to irritate the bladder and make the woman feel like she has to pee all the time. What's that? That's OAB. It's not OAB if there's an organic cause for it such as a bladder tumor that's sitting in the bladder. Ruling that out is super important and getting an inkling if there might be any a problem with the UA is great, so I love that point. What else should we be doing?
[Dr. Sarah Boyles]
The other thing is making sure that that patient is emptying correctly. We frequently do that in the office with an ultrasound machine, with a bladder scanner. You can cath the patient. Patients don't particularly like it, but it is more accurate. Bladder scanners can definitely be a little bit flaky so you have to make sure your scanner is reading correctly, but it is really important to make sure that someone is emptying correctly.
People that are neurologically intact will usually know if they are emptying correctly, but there are a lot of people out there who don't and that impacts how we treat things. It may push them into the overflow category, but any treatment that we do for leaking always makes it a little bit harder to empty so you really want to know how that patient is emptying at baseline. That is a very important thing to check.
[Dr. Suzette Sutherland]
Or also are they going to the bathroom all the time because they're never emptying well and when we say that we mean they're leaving a substantial amount behind. The tank is half full all the time and it doesn't take long before it fills up again and they feel the need to go to the bathroom again. We're not talking about leaving an ounce or two behind. That's not pathological so to speak, but if they're leaving over 100, 150, 200 behind, of course, it's going to influence their urinary frequency and that's the main reason why rather than saying that they have true overactive bladder.
[Dr. Sarah Boyles]
Checking a PVR, a post-void residual is so important because it absolutely has changed my diagnosis in the past. I've had patients who've come in with stress incontinence stories. "I leak playing tennis. That is the only time that I leak. No other symptoms." I think I even talked to this patient about a sling before I examined her and checked the PVR and then had to redo everything and redo the plan, but had a post-void residual of 500 cc's which is clearly abnormal. She's leaking because she's so full and that is really what needs to be treated. It's a very important part of the workup that should not be forgotten.
[Dr. Suzette Sutherland]
Yes, exactly. Then I would say to the general GYNs or general urologists that are out there that don't want to do work in this area, you find that as a problem, and then you send them on to somebody who specializes in this area or maybe some neuro urology or something that can identify a little bit more what's going on and what to do. You don't have to manage that just because you found it, but finding it is super important.
[Dr. Sarah Boyles]
Yes, I agree with that. I think those patients should frequently be referred on because there are more things that can be going on with them. It's not your typical incontinence patient.
[Dr. Suzette Sutherland]
Absolutely. I think you hit the two things on the head there, getting a UA and then a post-void residual. Those are two really basic and easy things to do that really are going to help you to differentiate what's really happening with this woman. I would say if we use a lot of bladder scan in our office as well, but if the bladder scan isn't adding up, it's not really making sense, then we're both in clinics where we have the utensils available to do a cath PVR, and I think that it's really important to get an accurate PVR. If it's not making sense, then check it because the bladder scan sometimes can have a certain amount of error.
[Dr. Sarah Boyles]
This is a little bit of an OBGYN aside. The bladder scanners are really looking at fluid. I've also had patients who've had big ovarian cysts and the bladder scanner is reading the cyst. Then it becomes really important to figure that out because you're pretty sure your bladder scanner is reading and there's something that's fluid-filled there, but it's not the bladder. When you check a straight cath, there's nothing there. That's an important thing to follow up further.
[Dr. Suzette Sutherland]
True. Very good point. I guess another question is this idea about questionnaires and what's the best questionnaire to try and diagnose this. I guess I'll just say in my experience, I think questionnaires really are most helpful when you're looking at outcomes research. I think asking the right questions, you get to your answer more quickly even than having lots of questionnaires that people sell out. I don't know what your thoughts are about that.
[Dr. Sarah Boyles]
I agree with that. I think questionnaires are helpful. They're an objective way of measuring if patients are better after a treatment and you can use them clinically that way. There are some abbreviated questionnaires to help with diagnosis and those can be very helpful if you're not comfortable with the conversation or want to try to abbreviate the conversation about incontinence. I think diagnostically, I can usually figure out why the patient is leaking just based on talking to the person.
[Dr. Suzette Sutherland]
I think a woman who comes in with complaints of urinary incontinence, I think if you're going to do a pelvic exam, what kinds of things are you looking for to rule out or rule in to help you with your diagnosis?
[Dr. Sarah Boyles]
I think it's always important to look at the patient's skin. You want to be looking at that external skin, seeing if there's any irritation, anything that needs to be addressed there. You want to be looking for prolapse because prolapse can definitely impact how the urinary tract system works. I would tell you when you're looking for prolapse, I would have you look for prolapse before you put a speculum in. Just spread the labia, have someone bear down or cough. I usually have patients cough because I find it's hard. People don't like to bear down when I'm looking at them because everyone's afraid they're going to pass gas and coughing feels a little bit easier.
If you put a speculum in, you're pushing everything back up so you can't see the prolapse. You just want to look and see if they have prolapse. You want to look at the urethra, see if there's anything abnormal there, see if there's a diverticulum that's there, make sure that all looks correct. You want to assess for genitourinary syndrome of menopause. Do those tissues look like they are lacking estrogen?
Postmenopausal patients or patients who are on contraceptives or are on a medication that decreases your estrogen level can absolutely have these issues. Breastfeeding can definitely cause those issues. You just want to look at those tissues carefully because vaginal estrogen has been shown to help with urinary incontinence. That is a very easy treatment, so you don't want to miss that.
When we're looking at the urethra, we look at the urethra to see if it's hypermobile, to check the mobility. I don't always do a Q-tip test anymore where you're putting a Q-tip into the urethra, but you want to look at that and assess it. I think it's important to do a good pelvic exam and feel and make sure that there aren't any masses there. I've definitely seen patients in the past who have had a cancer or who have ascites, and that is what is causing their incontinence, that increased abdominal pressure.
Then the last thing is pelvic floor muscle strength. You want to have that patient contract their muscles, ask them to squeeze like they're trying to hold in their urine. You want to grade their strength from 0-5, see if there's any tenderness there. Then the big thing is make sure that they can do that contraction correctly because so many people can't.
[Dr. Suzette Sutherland]
That was a good overview of that. The reality is if you're somebody who just wants to hear the patient who says, "Yes, I have some urine leakage," and you want to do a superficial or initial evaluation, but you know you're not going to be the one treating them and you want to evaluate. I think all of those things you're looking for any big, bad, ugly things that could throw off your diagnosis. Then what's the quality of the tissue look like?
I like the way you described that. Looking at how well they are able to do a Kegel, can they, can they not, do they have any clue as to what's going on down there. Those are the general things to begin with. As far as I think sometimes people think if I'm going to do anything in this area for this patient, then now I have to spend the time to teach her how to do a Kegel. The answer is to that, no, just identifying if the woman knows anything about how to do it herself. If not, then get her to the right therapist that can do all of that teaching.
[Dr. Sarah Boyles]
I think that's a really great point because if someone can do exercises on their own, they can do a Kegel contraction, then they can do a strengthening program on their own. You could send them home with instructions. They can do a peritrainer. If they can't do the contraction on their own, then they really need to see a pelvic floor physical therapist.
(4) Streamlining Incontinence Diagnosis: Avoiding Unnecessary Tests
[Dr. Suzette Sutherland]
Then before we get into the treatment options, just one more category of diagnostic things. We talked about a UA and a PVR, but really there's not much else that's really necessary for the initial evaluation. Sometimes we have patients who get referred to us and they've had a whole gamut of testing done and then they're sent to the specialist. I'm a little bit aghast. Why don't you talk to us a little bit about the things that are not needed?
[Dr. Sarah Boyles]
For the initial workup for incontinence, cystoscopy is not needed, urodynamics is not needed, a full pelvic ultrasound or imaging or a CAT scan, none of that is needed.
[Dr. Suzette Sutherland]
I should say sometimes as urologists, we see upper tract imaging like an ultrasound of the kidneys too, because they're complaining of incontinence. That's not necessary either.
[Dr. Sarah Boyles]
That's where it's so important to do the PVR. To do the urinalysis because if the patient does have hematuria, if they're not emptying well, then we want to do additional studies. We want to look at the upper tract and we want to do a cystoscopy and check those things. For the initial workup, it's not. I would tell you for my practice, even if I'm doing a sling, if someone has straightforward stress urinary incontinence, before surgery, I am checking a PVR, I'm checking their urinalysis, and I'm having them do a standing cough test where they have a full bladder, they stand and cough, and I look at them leak. I'm not doing anything more invasive and the data supports that.
[Dr. Suzette Sutherland]
That's great. How about bladder diaries? Do you use those much?
[Dr. Sarah Boyles]
I think bladder diaries are something that clinicians fear a little bit. It can be an intensive conversation with people. It can take a lot of time. I think patients notoriously fill them out in difficult ways using all different kinds of units. Six ounces here, cups here, milliliters here. I think it's a very important tool. Just like with weight loss, people don't realize what they're putting in their bodies.
Having someone do a voiding diary for three days really documents what they're doing. I've had patients who have done a voiding diary and they come back and they realize what they're doing that is creating the problem for them. They've been able to make the behavioral changes to fix that without even having a conversation. I think voiding diaries can also be used to track progress.
If you have someone do a baseline voiding diary and they feel like they've made no improvement, sometimes having them do another voiding diary can objectively help them see the improvement that they've made. It can also help with diagnosis. If someone's writing down, "Oh, I leaked during tennis. leaked with a strong urge to go to the bathroom." It can provide more diagnostic information too. I think voiding diaries are also an important part, but if it's something that someone doesn't want to embrace in the office, then I think it's a good time to send them to someone who specializes in incontinence.
[Dr. Suzette Sutherland]
This is just my opinion. I see a lot of people doing voiding diaries and they don't quantify. They just write down every time they have something to drink or every time that they void and every time that they leak and a little mark in a box. I think if you're going to take the time to do it, it's so helpful to quantify and have them measure what goes in and then measure what's coming out because you get really a lot of information about what is that bladder volume when you feel that urge to go?
Is it one or two ounces or is it 3 to 400 CCs? That tells you a very different story. Oftentimes the patients say, if you ask them, "How much do you void each time you go?" "Oh, a normal amount." For them, a normal amount is 50 CCs. That's their normal and that's not normal. I think that's really helpful. Certainly in the volume in aspect, that's often quite eye-opening.
Well-meaning providers tell patients all the time, just drink more water, but they don't give them any parameters. In fairness to the patient, they're doing what they're told and they're never given real concrete parameters. That's where I feel like we can step in to on average about two liters of fluid a day spread out evenly. Now they have something to work with and can really quantify it.
[Dr. Sarah Boyles]
It's objective data. I agree with you. We live in a society of over-drinkers. I feel like half my patients come in with their big Stanley cup full of water that they're filling up many times a day. They get that message about drinking from so many people. I think a voiding diary helps them realize how much they're drinking and it helps you step them back from that. I also think a voiding diary is critically important when you're evaluating nocturia to see how much they're emptying at night so that you can look for different causes of nocturia too.
(5) Initial Treatment Approaches for Urinary Incontinence
[Dr. Suzette Sutherland]
We've talked a lot about the diagnosis of urinary incontinence in women, how to differentiate different types of incontinence. Now let's move into the treatment algorithms. We really made the point too, that it really depends on what type of incontinence that the woman has that will determine the type of treatment that will be appropriate for them. One woman's incontinence isn't another woman's incontinence. One woman's treatment that might prove successful for her isn't the same for the next woman. Let's move now into talking about those types of treatments. Can you give us an overview of the different types of treatments that we have available today?
[Dr. Sarah Boyles]
I completely agree with you. The first step is figuring out the diagnosis and then starting down the treatment algorithm. For both stress and urgency urinary incontinence, the initial recommendation is behavioral treatment and physical therapy, and education but what is done in those sessions is quite different. Sending someone to pelvic floor physical therapy or having them do muscle strengthening on their own will resolve stress urinary incontinence in about 60% of women.
It's an important point. It's important to start there. Sometimes you really need to get patient buy-in. Physical therapy only works if the patient is engaged in that. It's important to know your local resources and your local pelvic floor physical therapist. For stress incontinence, they're really focusing on strengthening the pelvic floor. They're focusing on breathing. Then it's not quite enough to have a strong pelvic floor. You also have to engage those muscles at the correct time. It becomes very educational.
I think it's important for all women, but there are definitely different things that the pelvic floor physical therapist will recommend for women who are very athletic or using their bodies in more extreme fashions, or even helping patients modify their workout routine so that they're doing exercises in a way that doesn't induce leakage. With urgency incontinence, it's important to have a strong pelvic floor as well.
They're also focusing on techniques like urge suppression, where contracting the pelvic floor will get the bladder to relax. That can dramatically impact women and help women with their urgency incontinence. They're focusing on bladder irritants. They also frequently will do bladder retraining, where they're lengthening the interval of time between voids, which can help with frequency and urgency and just reset the system.
[Dr. Suzette Sutherland]
When we look at pelvic floor physical therapy, we know that that's the only type of therapy for the most part that really can effectively work for both stress incontinence and urgency urinary incontinence. As you mentioned, you're doing different things at those physical therapy sessions, depending on which problem you're trying to target. I've heard the physical therapists themselves use the terms up training and down training.
Up training for I'm strengthening just to get stronger so I don't leak when I cough or sneeze. Down training to get the bladder, pelvic floor muscles, everything to quiet down for that urgency frequency issue. I think those terms are helpful for patients to understand when you say up training, I'm strengthening. Down training, I'm trying to learn to relax and control that bladder and pelvic floor.
[Dr. Sarah Boyles]
Some people will do some of this training in their clinic. Review urge suppression, make sure that the patient is contracting their muscles correctly. That all depends on how your clinic is set up and how much time you have. Sometimes that can be very time-intensive. I think if someone can do a pelvic floor contraction on their own, they don't have to go to pelvic floor physical therapy. They can do it on their own.
You also have to be very mindful of the additional benefits that pelvic floor physical therapy gives because definitely, there's a lot of coaching that happens there. There's a lot of accountability and someone is much more likely to stick to those exercises for the needed timeframe because you have to do those exercise for a minimum of six weeks to see improvement and sometimes up to three months. It really keeps people honest and keeps people doing it. Some people can do it on their own, but most of us need a guide.
(6) The Effectiveness of Intravaginal Devices in Urinary Incontinence Treatment
[Dr. Suzette Sutherland]
We know that just handing them a handout on Kegels and say go home and do these is not effective. They will come back at their next follow-up appointment if they come back, six to eight weeks and they won't have done them effectively for sure if they've done them at all. We know that's not effective for all kinds of physical therapy. What do you think about some of the intravaginal devices or the devices that help people do the Kegels? What do you use in your practice and do you think that they're really helpful? At what point in the patient's education are they helpful?
[Dr. Sarah Boyles]
I think it all depends on the patient. If someone can do an effective Kegel contraction, then I think those devices will work if that person is committed to putting something in the vagina and doing those exercises regularly. Some people will do that and some people won't do that. There isn't as much accountability. You're more likely to do the exercises if you're checking in with someone regularly. There isn't as much coaching. I think all of those, softer points become really important.
For somebody who is very committed to doing those exercises and very motivated, I think that it is an additional tool, but it definitely doesn't work for everybody. The issue with a lot of the peri-trainers is that the majority of them cannot distinguish between a contraction and a Valsalva. They measure pressure. Someone could be Valsalving and thinking that their strength is increasing, and in reality, they're not doing anything. That's one of the reasons it's really important to make sure that they contract correctly. I really like the Leva device, L-E-V-A. The reason for that is that that device actually detects muscle movement. It can distinguish between a Valsalva and a contraction.
[Dr. Suzette Sutherland]:
It gives good, adequate biofeedback so to speak, and giving it accurately. That's really important.
[Dr. Sarah Boyles]
There are some people who don't have access to a pelvic floor physical therapist. There definitely are not enough pelvic floor therapists in all parts of the country. I think that device really gives a lot of benefit and it also has some coaching associated with it, too. Some of the other peri-trainers do as well. I think that coaching and having someone you can reach out to and talk to is really helpful for a lot of women.
[Dr. Suzette Sutherland]
That device is not available over the counter, though. It's available by prescription only. That differentiates it a little bit, too.
[Dr. Sarah Boyles]
There are many of these that are available. If a woman goes online, and I get asked this all the time, I think the thing that you really want to look for as the consumer is something that not only will because some electrical stimulation to cause contraction of the muscle, but also give you appropriate to feedback right to your point. Certainly, something that requires a prescription or a conversation with a physician, it's going to be validated as well.
Our physical therapists, they like the one called K-Goal. There's another one, Flight, that's out there. It uses a little bit different oscillation movements to try and improve the muscle strength. All of these also have a feedback mechanism, which is really important as is teaching the woman how to do it correctly. It's not just doing it passively for the woman. The woman is learning how to do the appropriate exercises. Some of them have different exercises and will change the exercises over time.
They become more difficult over time. The Perifit is the one that is most like a game. They call it a Flappy Birds game. Some people really like that. I think the other thing to be mindful of is cost. If someone is looking online and one is much cheaper than the other, and it fits these criteria, I would say pick the cheaper one.
(7) Weight Loss as Part of the Incontinence Treatment Plan
[Dr. Suzette Sutherland]
Aside from doing exercises for strengthening for stress incontinence, if that's not sufficient, sometimes the problem is too far gone, and it might make them better, but it's not going to really solve the problem 100%. Take us down the algorithm. What are the next things that we can offer?
[Dr. Sarah Boyles]
I think one of the other important things to talk to people about is weight loss because we know that with weight gain, incontinence gets worse, and vice versa with weight loss, incontinence gets better. That with conservative management is always an important thing to bring up to someone so that they realize that. Sometimes when you talk to a patient, they'll say, "Oh, yes, that makes a lot of sense. I just gained 15 pounds, and my incontinence has clearly gotten worse." They may start focusing there.
[Dr. Suzette Sutherland]
Although we do see that it's reported in our literature improvements that happen just with 10, 20-pound weight loss, I do also try to make the point to women that it's not the only issue. To say if I would only lose 10 pounds, my problem would be solved. I think sometimes, women fall into this body image trap. I certainly see bone-thin women that have a lot of incontinence. So I say that to patients so they understand it's a piece of the puzzle. Things would improve if you are that much overweight and you lose some weight. If someone's just five pounds vacillating one way or another, that's not going to be the answer for them.
[Dr. Sarah Boyles]
t's true. You have to be careful not to play into people's demons. Usually, what I talk to people about that someone says, "Oh, I've gained 15 pounds. My incontinence is so much worse." Then I'll say, "If you lost the weight, then you'll be the way you were a year ago before you gained that weight. It's not going to totally go away. The weight loss might bring you back. You're right, it is one tool. It's not everything. Also, for weight loss, people need to be more active. If someone has stress incontinence, and you want them to exercise more so they can lose weight, and it makes the problem worse, that can be difficult for somebody to do.
(8) Choosing the Right Urinary Incontinence Treatment Device: Cost, Comfort & Effectiveness
[Dr. Suzette Sutherland]
Let's look into their other devices that are easy devices people can recommend that women try. There are some urethral seals that are available, there are certainly a vaginal pessary. Let's chat a little bit more about that. I don't have much experience myself with the urethral seals. What can you say about those?
[Dr. Sarah Boyles]
The urethral seal is exactly what it sounds like. It's a little patch that you put on the urethra and it stops small amounts of incontinence. You have to take it out to void. It's not reusable, it's disposable. I think it can help for someone who leaks a small amount in a specific situation. It's not something that you would use daily in an ongoing fashion just because of cost, I think. I think if you're leaking just at a specific time, it can be very helpful.
[Dr. Suzette Sutherland]
Is a prescription required?
[Dr. Sarah Boyles]
No, it's over the counter. The brand that I've seen with that is called Finesse. It's funny when people come to talk to you about incontinence because sometimes they're worried about a specific situation, "I'm going to a wedding, I'm doing this thing and I really don't want to leak at this particular point in time." I think for that type of situation, it's very helpful.
[Dr. Suzette Sutherland]
Sounds like it's good for situational things, right?
[Dr. Sarah Boyles]
Correct.
[Dr. Suzette Sutherland]
Traditionally, the other thing we use in the vagina, not in the urethra, would be pessaries, a vaginal pessary that has a little extra bumper that sits under the urethra. There are other pessary-like things over the counter too, as well as with prescription. Tell us about those.
[Dr. Sarah Boyles]
Pessaries can be used for prolapse, but there are specific pessaries that are used for incontinence as well. They will improve stress incontinence and only stress incontinence in about 60% of women. I really like pessaries. I think pessaries are a great tool. I think for women who leak on a run, putting in a pessary before they run is a brilliant idea and super helpful. You can wear a pessary all day long. It depends on the pessary. If you have a medical-grade pessary, incontinence pessary, you can wear it all day long, or you could just wear it during specific activities.
I think from the practitioner's side, pessaries are a little bit intimidating, because you have to have the patient come in, you have to do a pessary fitting. If you're not doing a lot of pessary fittings in the office, it may take you a long time. I just saw a patient yesterday who had this experience with her OB-GYN, where she really wanted a pessary, and that provider's poo-pooed it, and she didn't get a pessary. I'm sure that's just because they may not have had pessaries in the office, or the fitting can take a little bit of time.
[Dr. Suzette Sutherland]
Just didn't have time, right? I'm a big fan of having a specialized provider, whether it's a nurse practitioner or a PA who does your pessary fittings for you as the MD, or you have a separate time set aside, the patient comes in for the pessary fitting. I talk to patients about, there's an art to fitting pessaries, and if someone just shoves a pessary in and sends you home with them, and then you spit it out the first time you go to the bathroom, no wonder, it wasn't really fit to you. That happens to people because of lack of time, and so I agree completely.
[Dr. Sarah Boyles]
That's a real issue, and that's what we do in the office too, my nurse practitioners do the pessary fittings. There are also pessaries that are available over the counter. The Impressa is a pessary that's available over the counter. I would tell you, you can give someone that information, they can just go and get it. They're a little bit difficult to find in the store these days. I think it's easier to find them online and they can try the Impressa. Sometimes, if I am strapped for time or if there's something difficult in the schedule, I'll send someone out and say, "Why don't you try the Impressa and see if it works for you.
If it does work for you, then we will get a more permanent pessary for you." Because the Impressa is disposable. It comes in a couple of different sizes.
[Dr. Suzette Sutherland]
To clarify, it's for people who know what a pessary looks like, the traditional pessary anyways. The Impressa really is a fancy tampon, and it comes in different sizes, you were about to say there. It's much like a tampon, but does the same supportive action as a pessary does, but not quite as much as a well-fit pessary, probably.
[Dr. Sarah Boyles]
The insertion looks like a tampon, so it's all compressed. Then once you take out that applicator device, it explodes, it's almost like a tube.
[Dr. Suzette Sutherland]
Can we say expands, so women don't get scared about it exploding in their vagina?
[Dr. Sarah Boyles]
That's a fair point. The other thing I would say about the Impressa is usually when I have patients place an Impressa, I have them lubricate it because sometimes the material that it's made of can be a little bit irritating to people. I usually have them lubricate it before they place it.
There's the Impressa, which is available over the counter. There's a lot of development in this space. There's always new products coming to market. The other one that I use frequently is the Uresta. The Uresta was developed by a Canadian urogynecologist. It's over the counter in Canada. It's available by prescription in the United States, although it is going to be available over the counter soon in the United States, I think this summer, 2024 at some point in time.
The Uresta does not require a fitting appointment in the office. There are five sizes. Patients are given three sizes and they try them on their own. I've had pretty good results with the Uresta. The only thing that I would tell you about the Uresta, it looks like a plug and it's pretty firm when you feel it. When I recommend this to patients or when I prescribe it to patients, I always have to warn them that it looks like it would be really uncomfortable. It is not uncomfortable, so just go ahead and try it because when you look at it is not inviting. As long as it's effective.
Then you can always have someone come in and do a traditional pessary fitting. The Uresta can be worn all day long. The Impressa I think can be worn for six to eight hours. Then the Uresta, you should replace after a year. All incontinence pessaries that we fit in the office, you can wear for several years at a time.
(9) Stress Urinary Incontinence: Urethral Bulking, Surgery & Specialist Referrals
[Dr. Suzette Sutherland]
Good. Those are some basic things that the general gynecologist, general urologist who sees a woman with stress incontinence can recommend and initiate even. Let's quickly move on to, if these things aren't helping, then a lot of times the generalist just throws their arms up and says, "Well, I don't know what else to do. I don't do significant work in this area." What should they do? They should refer them to a specialist, but I think the generalist needs to know a little bit more about what are the possibilities that will happen to that patient or treatment options that will be offered. Can you quickly run down that algorithm for stress incontinence?
[Dr. Sarah Boyles]
Yes. After pelvic floor strengthening and pessaries, the next two options are really urethral bulking and surgery. Urethral bulking has become more popular over the last couple of years. It does not work as well as a surgery, but for a lot of patients, it will improve their incontinence in a very minimally invasive way, because you're just injecting a material into the urethra. That can be a really great option for people.
I particularly like that option for women who are having leaking and are done with their child bearing. That is an additional tool. Then there are surgeries. The most common surgery in the United States for stress incontinence is a mesh sling. You can absolutely do a mesh sling without, or you can absolutely do a sling without mesh. There are other procedures, but the mesh slings at this point are minimally invasive, they're quick, they're very effective, and patient satisfaction is very high with them.
[Dr. Suzette Sutherland]
The data that is available thus far on the autologous slings that are mid urethral slings, so what you're saying is taking a mesh sling and the middle that goes underneath the urethra has been replaced with some either cadaver, fascia, or something like that. Those haven't been shown to last as long as the mesh option, just so people understand that. That's why the mesh slings have just been worldwide as the number one procedure that we have for stress incontinence today.
[Dr. Sarah Boyles]
The benefit of the mesh is that it works the same in everybody. whereas someone's own autologous tissue, some people have great tissue, some people don't have great tissue, and it is a much bigger surgery when you're harvesting someone's own tissue.
[Dr. Suzette Sutherland]
Then aside from the urethral bulking agents or the mid urethral sling, there are other options that we do have available for people who have significant incontinence and don't respond to these other things we've just mentioned. Now we are talking about a more significant surgery, sometimes an autologous fascial pubovaginal sling, sometimes an Open Burch procedure. There are other creative things, but clearly having the patient see a specialist in this area would be advised. This is what they're needing.
Let's move on then quickly to the urgency urinary and incontinence category. The treatment algorithms, again, we talked about behavioral things, dietary things, pelvic floor exercises for down-training instead of just focusing on up-training. You made the point that strengthening is important too, but the focus is on teaching control. Then when we go beyond that, the woman is still having trouble. What else do we need, or what do we add to that? Let's talk about the next tier of treatment options.
(10) Urgency Urinary Incontinence: Medication, Neuromodulation & Emerging Therapies
[Dr. Sarah Boyles]
We've always, or traditionally, we've thought of overactive bladder and urgency incontinence of having first, second, and third line treatments. Where first line is strengthening and behavioral interventions, and then second line is medications. There are two big categories of medications. There's anticholinergics and then the beta-agonists. Medications work at about 60% of patients. The side effect profile is high, and so that means the discontinuation rate is high.
With anticholinergics, there's a lot of new data coming out about the risk of memory loss and dementia, and that risk increases the higher the dose and the longer you're on that medication, also, the older the patient. That makes anticholinergics at this point in time, a difficult medication to recommend. The risk exists with all of the anticholinergics, but it looks like it's the highest with the oxybutynin immediate release. If someone is a candidate for an anticholinergic and it really fits them the best for lots of different reasons, that's a medication that you would want to avoid and start with one of the other medications.
[Dr. Suzette Sutherland]
That's a good point. Then also, just from a practical standpoint, all the anticholinergics, are the ones associated with dry eyes, dry mouth, constipation, but some to varying degrees. There is one anticholinergic, that's Trospium chloride or Sanctura, that does not cross the blood-brain barrier. There's no risk of dementia or memory loss, or having a significant fatigue because I feel cloudy head, anything like that. That would be one of the anticholinergics that don't affect the brain, so to speak.
[Dr. Sarah Boyles]:
I think that there has been some association with it because, that's the medication that I always want to give because theoretically it shouldn't. I think in those large studies there has been some correlation.
[Dr. Suzette Sutherland]
I'm not aware of those. The studies I'm aware of, have all been really with oxybutynin and Detrol, not with Trospium chloride. Then we look pharmacologically, we do see that it's a quaternary, amine and not crossing into the blood-brain barrier from a theoretical standpoint too, but we can take a closer look at that.
The other thing is to look at the beta agonists. When we talk about the OAB medications, they don't have all of those anticholinergic side effects. They have a few other things that need to pay attention to of their own. There's a reason to use maybe beta agonists versus the anticholinergics, although insurance will always steer you towards the anticholinergics. Again, the cheapest tried-and-true, which is oxybutynin, and you already mentioned that one. Therein lies the difficulty and the work that we as practitioners need to do, get the insurances to change their algorithms and allow patients the therapy that they need.
[Dr. Sarah Boyles]:
That's a huge practical problem in the office right now, because we do always want to start with the beta agonists and getting them, they become prohibitively expensive for patients, although they work very well and are much better tolerated.
[Dr. Suzette Sutherland]:
If we move away from the medications, then we know that you already mentioned there's not much compliance oftentimes, long-term compliance, because of the side effects, or people just don't want to take another drug. Then what other options are there available that we have today?
[Dr. Sarah Boyles]
It's a pretty exciting time, because there are a lot more interventions that are available for overactive bladder, and I think that's a really important thing to communicate to patients, that there are lots of treatment options and lots of things that they can explore. If medications don't work, then we're looking at third-line therapy, although those lines of therapy are being changed a little bit right now, and we can talk about that in a little bit. That includes Botox, it includes nerve stimulations, and so with the nerve stimulations, you can stimulate the third sacral nerve, and that can dramatically improve overactive bladder, as well as retention of fecal incontinence. That does require a surgery.
You can also stimulate the tibial nerve, which runs along your ankle, and the tibial nerve you can stimulate in many different ways. You can stimulate that with a TENS unit, you can stimulate that with percutaneously with almost an acupuncture needle, but that requires patients to come into the office once a week for 12 weeks. There are also newer implants, so you can permanently stimulate that nerve. There is also a new transcutaneous boot that patients can put on that will stimulate that nerve, as well.
There are lots of different modalities that you can look at. The nerve stimulations are becoming more popular and more common. I think for a lot of my patients, doing something that doesn't require systemic therapy, like a medication, doing something that is a more local therapy, like Botox or nerve stimulation, is more appealing to them because of the side effect profile. There are lots of different options out there.
[Dr. Suzette Sutherland]
Some of those, a general GYN or urologist might want to offer in their office, but I think mostly they're probably best served seeing a specialist who understands these therapies and also understands the progression of these therapies, because if one isn't working, like the transcutaneous, then maybe the percutaneous, and then maybe the implantable, you can go up the ladder a little bit. Rather than lose the patient because they say, oh this form of neuromodulation doesn't work because we tried the boot and it doesn't work.
[Dr. Sarah Boyles]
Some patients will like the percutaneous, but then after that 12 weeks they have to come into the office for maintenance, and maybe after a period of time they'll say, "Look, simulating this nerve works really well for me, but I'm tired of coming to your office. Could we do something more permanent." There are lots of different things that we can offer people.
[Dr. Suzette Sutherland]
I think people that are in our audience here are pretty familiar with the traditional PT&S with a little acupuncture-like needle, and they come in, as we said, and get their therapy once a week. With now all of the implantable options, that allows people to have daily therapy, if needed. Just to augment and enhance their response. Therein lies some of the great innovation that's happening in this space and giving patients a lot of flexibility for their treatment and really tailoring it to what they need, not being so prescriptive.
Speaking about the innovation in this space, there's more procedures that are coming down the pike looking at neuromodulation as a form for treatment, not only for urgency incontinence, OAB and urgent incontinence, but also for stress incontinence. For those patients who have mixed incontinence, an implantable neurostimulator may be able to help them with both of their problems. Now, the mechanism of action of how the stimulation is happening is pretty darn sophisticated and works differently for these two different problems, which is the really sophistication of these devices. It's really exciting to see that innovation in this area and encourage people to watch for it coming down the pike.
There are other things, I think, that people hear about, especially they get online and they learn about these. Can you talk a little bit about some of these, and are they really that helpful? Have you had experience with them? I know some of the more simpler things I haven't had good experiences with.
[Dr. Sarah Boyles]
I think one of the things that patients ask me about frequently is the Emsella chair, right, which uses a magnetic impulse to contract the pelvic floor and will supramaximally contract the pelvic floor. Whether that actually works, there isn't a lot of data suggesting that it works. We really don't know how long it lasts and it's a very expensive option. I've never really been able to figure out how to put that in my algorithm, and so that isn't something that I use routinely, if at all.
The other thing that I'm super excited about is, there's some research going on with stem cell injections for stress urinary incontinence, which I think has the potential to be a big game-changer in this space, too. We'll watch for more of that down the road, for sure.
[Dr. Suzette Sutherland]
Again, we've talked a lot about the diagnosis of urinary incontinence, the basics thereof for your generalists that are out there, general GYNs, general urologists, and then the basic treatment options. I'd like you, if you could just do a quick summary, just an algorithm, what is it that the generalists should do to evaluate their patients, and then what is it the generalist can do to start the treatment before passing them off to a specialist?
[Dr. Sarah Boyles]
I think this is a huge problem for women, and I think the most important thing to do is to really acknowledge and validate the symptoms. This is something that women will frequently bring up at the end of an appointment. It is not always a short conversation, and so I think really validating the symptoms is the most important thing.
In terms of evaluation, you want to check their urine, make sure they're not having a hematuria or ongoing infection. You want to make sure that they're emptying well and checking a PVR, and then making sure there isn't anything else going on. There aren't any masses, neurologic symptoms, anything like that. I think that's really the bare bones workup that you need to do in this situation.
Then you need to figure out what the diagnosis is, urgency, stress, urinary incontinence, urgency, stress, mixed, or overflow. At that point in time, you can decide what to do. You could teach them how to do Kegels, you could send them to a pelvic floor therapist, but I think the important thing is really validating their symptoms. For people who are really interested in doing incontinence, I think knowing your pelvic floor therapist in your area is very important, knowing who you can send them to, knowing who the specialists are, people who really like this work. Then you could recommend a pessary, you could recommend the Impressa or the Uresta, you could recommend a pelvic trainer or The leva, if you don't feel like they're doing as good of a contraction. Those are the places where I would have somebody start.
[Dr. Suzette Sutherland]
I think a big point that you mentioned there, too, is as a busy clinician, you know what you have time for, you know what you have maybe even an interest in or not, and so doing a little homework to identify what are my resources in my community, so that you can address the woman's issues, but just honestly say, "I don't work in this area very effectively, these are the things I might be able to start for you." But if you really don't want to do any of it, send them on, but know who's in your community that you're sending them on to. That can be extremely helpful.
[Dr. Sarah Boyles]
That's one of the reasons that I created my online platform, thewomensbladderdoctor.com, to help educate patients. There are some videos, so if you're someone who doesn't want to do any of this and you're not sure where to start with the education, you can send them there and they can get basic information there, too.
[Dr. Suzette Sutherland]
Great. This has really been a wonderful and educational session. Hopefully, I think people will glean a lot from this. This has been Sarah Boyles. She's a urogynecologist that's in the Oregon area at the Oregon Clinic in Portland, Oregon, and CEO of the Women's Bladder Doctor where she has her own website and started a podcast just educating women about their pelvic area, and mostly about urinary incontinence and prolapse. Thank you very much, Sarah, for being with us here today.
[Dr. Sarah Boyles]
Thank you.
Podcast Contributors
Dr. Sarah Boyles
Dr. Sarah Boyle is a urogynecologic surgeon at the Oregon Clinic in Portland, Oregon.
Dr. Suzette Sutherland
Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 6). Ep. 61 – Evaluating Female Urinary Incontinence: Essential Steps for the Generalist [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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