Urinary and Bowel Incontinence

Additional Info

• Audio File:uab/ua033.mp3
• Doctors:Richter, Holly
• Featured Speaker:Holly Richter, PhD, MD
• CME Series:Medical Innovations
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4221
• Guest Bio:Holly Richter, MD, PhD, J. Marion Sims Endowed Chair in Obstetrics and Gynecology.
  
  Learn more about Holly Richter, PhD, MD 
  
  Release Date: 10/3/2017
  Reissue Date: 10/5/2020
  Expiration Date: 10/5/2023
  
  Dr. Richter has the following financial relationships with commercial interests:
  
  UpToDate - Royalties
  Pelvalon - Grants/Research support/Grants Pending; Consulting Fee
  
  Dr. Richter does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host): As life expectancy in developed countries gradually increases, obstetrician/gynecologists are encouraged to be familiar with disorders of the elderly population. Half of all women are likely to experience some incontinence in their lifetime, and about 10% will have surgery for incontinence and/or prolapse. Fortunately, most incontinence problems can be successfully treated. My guest today, is Dr. Holly Richter. She’s the Director of the Division of Urogynecology and Pelvic Reconstructive Surgery at UAB Medicine. Welcome to the show, Dr. Richter. Explain a little bit about urinary incontinence and the etiology of it. What are some of the most common causes?
  
  Dr. Holly Richter (Guest): Okay, so for all women – if we take a look at all women in the US 20 years of age and older, almost 20% of these women will have symptoms of urinary incontinence. Urinary incontinence is a condition where a woman loses the ability to control urine. There are a couple of different types of urinary leakage. Stress urinary leakage is the type of urine leakage when a woman undergoes activities such as running, jumping, coughing, sneezing. There’s an increased pressure transition to the pelvic floor, and this results in urinary leakage.
  
  Along with stress urinary incontinence, there’s another type called urgency urinary incontinence. That’s a type of incontinence where a woman has a strong urge to go to the bathroom that she cannot defer. She can’t get to the bathroom in time, and she will leak. And probably the biggest group of the type of incontinence is mixed urinary incontinence, and that’s where a woman has both stress and urgency urinary incontinence.
  
  Melanie: How important is early diagnosis as being crucial to improve the outcome prediction? Do you take a thorough history, and is that essential to the evaluation of incontinence?
  
  Dr. Richter: A thorough history is very important because you want to get the correct diagnosis – the correct type of urinary leakage. Typically, for all urinary incontinence, the primary approach to its treatment is behavioral – the use of pelvic muscle exercises, watching the water and other fluid intake, staying away from caffeine, these types of issues. Some of these types of strategies work better for stress incontinence as opposed to urgency incontinence. There are also medications that we can use in women that have urgency incontinence that won’t help women that have stress leakage. The diagnosis is very important.
  
  Melanie: Dr. Richter, since many women – almost half the women won’t report it to their doctor, whether it’s embarrassing or they don’t think that anything can be done, should physicians take an active approach and ask specific questions such as onset, symptoms? Should this be something that physicians just do as a regular thing?
  
  Dr. Richter: That’s a great question. I do think that as a part of a normal review of systems when a woman presents to her primary care provider regarding her yearly checkup that he or she should ask whether she has symptoms of urinary leakage, bowel leakage, or if she feels or sees a bulge coming down from the vagina. All of these conditions are considered pelvic floor disorders and can be helped.
  
  Melanie: And you mentioned management – speak about your nonsurgical intervention, what you do when you talk about the exercises and behavioral lifestyle -- how do you encourage women to follow these? Do you teach them how to do something like the Kegel, for example?
  
  Dr. Richter: We have a specialist that we partner with in Urogynecology Care Clinic and they essentially provide strategies including how to isolate the pelvic muscles, how to use them, when to use them – when a woman is doing various types of activities – to help close off that urethra so that when she’s doing activities or when she has a strong urgency to go to the bathroom she can keep that urine from passing from the bladder to the urethra. Along with that is thinking about the types and amounts of fluids that a woman may take in during the course of the day as well as things like regular voiding throughout the day.
  
  Melanie: And what about medicational intervention? People hear these things on television late at night and in the media, what do you tell women when they ask you about all of these different treatments?
  
  Dr. Richter: Medications that are out there are essential medications for women with urgency urinary incontinence. The meds to help calm the bladder muscle. When a woman has a strong urge to go to the bathroom, that bladder muscle is trying to contract when she’s not typically in a socially acceptable position to be able to act on that. Therefore, the medications typically will give her a bit of time to be able to get to the bathroom.
  
  Now, the problem with the use of medications is that they also have side effects. They cause dry mouth. They can cause constipation. They can cause dry eyes. It’s nice if a woman can have a behavioral therapy approach such as using her pelvic muscles, such as watching her fluid intake – not only amount of fluid intake, but the type of intake – so that she may not have to depend on medication to control this condition.
  
  Melanie: And what about other interventions, Dr. Richter, such as Botox, or SNS?
  
  Dr. Richter: Yes, prior to even going to Botox and SNS for stress leakage the use of pessaries exists. These are devices that are put into the vagina. They help support the bladder neck. There’s even some data which suggests that a pessary may also help with urgency urinary incontinence. Once a woman has exhausted these nonsurgical approaches, these behavioral approaches including pelvic muscle exercises, strategies, the use of medications. Then for urgency, urinary incontinence Botox and Sacral Nerve Stimulation are options that are available for women.
  
  Melanie: What about the psychosocial impact of untreated incontinence?
  
  Dr. Richter: Oh, that’s an immense issue. Untreated incontinence keeps women from going out, from exercising, from interacting with her friends, even family. It is a condition where it can cause social and psychological isolation for women, so it’s very important to proactively ask about this condition and to help a woman get treatment for it.
  
  Melanie: Is it likely to worsen with time? Are there any studies about the menopausal transition? Does that seem to be the age that it starts to worsen?
  
  Dr. Richter: That is a very insightful question. As women go from the reproductive to the post-reproductive time of life, as many of you all know, the ovaries start to shut down. Systemic estrogen levels go down. Associated with this is vaginal dryness, increasing bladder irritability. These things go hand-in-hand with the menopausal transition. Vaginal estrogen is very important to manage these symptoms.
  
  Melanie: Wrap it up for us and let other physicians know what you’d like them to know about treating urinary and bowel incontinence and when they might refer to a specialist.
  
  Dr. Richter: In terms of urinary incontinence, I think a generalist could talk to a woman, see what her pelvic muscles are like, and encourage her to use her muscles to help urine leakage. If this is not something that is successful for her on her own, she should be sent to a specialist for treatment.
  
  Similarly, with bowel incontinence -- which is probably an order of magnitude of higher impact compared to urinary incontinence -- we have many strategies, many treatments for this including, again, behavioral therapy, the use of other strategies, perianal injections, vaginal devices and anal devices, as well as Sacral Nerve Stimulation, which treats bowel incontinence.
  
  Melanie: Thank you, so much for being with us today, Dr. Richter. That’s great information. A community physician can refer a patient to UAB Medicine using the MIST Line at 1-800-UAB-MIST, that’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks, so much for listening.
• Hosts:Melanie Cole, MS