Non-Surgical Treatment Options for Female Incontinence

[Dr. Yahir Santiago-Lastra]
When women come into my clinic seeking care for urinary incontinence, it can be one of two main types. They either have stress incontinence which is leakage when they cough, laugh, sneeze, or exercise. Or they can have urgency incontinence or what we call overactive bladder and that is leakage that is associated with a strong urge with urinary frequency or incontinence associated with that urgency.

It is really important when I talk to women to do three important things. Number one is to get to know them and to understand how this problem is impacting their life because that factors into my decision making for them. Two is what their expectations are. Some women come into the office already knowing a little bit about what they want or don't want to do, so I don't want to patronize them or give them an option that doesn't fit into what they were expecting. Three, and probably most importantly, honestly, is to distinguish whether their problem is stress predominant or urgency predominant, because those two domains of incontinence are treated completely differently and you definitely don't want to get them mixed up or you're going to have a patient that is quite bothered. Most women have both, but there is usually one that is predominant over the other and so I try to distinguish that in my conversation with the women that I treat.

[Dr. Jose Silva]
And that is based purely on the complaints of the patient, which one you determine is more dominant?

[Dr. Yahir Santiago-Lastra]
Yeah. You know, I'm in an academic center, so one of the things that might distinguish my practice from someone who is in private practice, for example, is that we have really intense questionnaires. Patients don't always love them. They come into the clinic and they could spend maybe 10, 15 or 20 minutes filling out a questionnaire. So by the time I see them, I have a pretty good idea if they have stress incontinence, urgency incontinence, or a mixture of both. But, it is always important to talk to them because sometimes women may not want to fill out all the questionnaires or they may fill them out in a way that is perhaps a little misleading or doesn't answer their concerns perfectly. So, that's what I tend to do is sit down with them and distinguish those two and yes the symptoms are what distinguish one from the other.

[Dr. Jose Silva]
Yes, most of those patients are already frustrated going to other physicians, jumping from medication to medication, and not accurately knowing what they have or treating what they have. So they go to you, the specialist, and they want an answer or a solution immediately. So sometimes that is very tricky and I bet in your case to slow their pace down with the patients and say, "We are going to go through a process and see what's going on." and then offer a solution. Do you find that also in your practice?

[Dr. Yahir Santiago-Lastra]
Yes, that is 100% what I see. I tell my residents this a lot. I tell them it is very common in my practice for me to spend that first visit getting to know the patient and doing a pelvic exam. Whenever they come in with these complaints of urinary incontinence, I will do a pelvic exam. It is not mandated from a guidelines perspective, but most of the time it is going to be something in your toolkit that you will want to do so that you can strategically plan what kind of interventions you want for the patients.

I tell my residents and fellows all the time that, very often, we will have that first visit and the patient gets so much information and options to treat their problem that they can't really make a decision right then. So, I'll often schedule, especially now in the advent of telemedicine, I'll schedule phone calls or telemedicine visits in a few weeks after that initial visit, to go over those options that I talked to them about and to actually schedule either an intervention or therapy or something else. That may not be something convenient to everyone in practice. It really depends what kind of a practice you have, but that works really well for me.

[Dr. Jose Silva]
You mentioned pelvic floor exercises. Do you send everybody, prior to the procedure if they have stress incontinence, everybody has to go to pelvic floor or there are patients that you decide "Hey, it might not work, let's just go into more invasive procedures or something else."

[Dr. Yahir Santiago-Lastra]
I'm a big believer in pelvic floor physical therapy. I think that it is really nice for women to learn to take care of their pelvic floor and to understand the muscles that are there. I think it can be really helpful, not just for incontinence, but also for their sexual function. But, I leave it up to the patient and I explain to the patients that, if you really want pelvic floor exercises to work, you have to dedicate yourself to that really for the rest of your life and you have to be committed to it. It is like undergoing any sort of therapy or exercise program, the more you put into it, the better results you are going to see. Some women are really honest with me and they will tell me, "Look, this is not something that fits in with my lifestyle." and that's totally fine. Some women do it and prefer to do that as opposed to going straight into surgery and they come back after the therapy, feeling like their symptoms have improved to the point where they don't feel like surgery is in the cards for them any longer and I consider that a success, as well.

[Dr. Jose Silva]
Yeah, definitely and also access to the pelvic floor. Not everybody... I'm in a community hospital and we don't have one, so they have to drive half an hour or 45 minutes to their appointments sometimes. Younger patients do tend to go. I have tried to push them that way first, but definitely older patients that might have problems driving and all that. I mean, I mention it to them and see what they think but most of the time, I end up doing a procedure.

[Dr. Yahir Santiago-Lastra]
Yes, I think my practice would be in line with that, too. Access to care for pelvic floor physical therapy is really problematic. I take care of a lot of minority patients and under-served patients and usually there's only one pelvic floor physical therapy location that's contracted with that insurance and so it can be really limiting for women who might be interested in doing it, but their insurance either won't cover it or won't offer them a location that's close to where they live. I am fortunate that now my institution has set up some internal pelvic floor physical therapy, but for now it is only in La Jolla. So, patients that live 45 minutes away in Bonita or in Chula Vista or somewhere else are limited to that location and it doesn't always work for them. I do get patients who end up choosing something else, just because they don't have that access which is definitely a disparity.