What is the Difference Between Urge and Stress

Transcription:

Deborah Howell (Host): Have you ever wondered if your sudden urges are normal or maybe not so normal? Well, we're going to try to answer that for you today by talking about the difference between urge and stress when it comes to incontinence.

My guest is Amanda Phelps-Jones, a women's health nurse practitioner at Deaconess, the Women's Hospital. Welcome, Amanda.

Amanda Phelps-Jones: Hi. Thank you.

Deborah Howell (Host): Lovely to have you here. Let's start with some definitions. What is urinary incontinence?

Amanda Phelps-Jones: Urinary incontinence is anytime you lose urine unintentionally and there are a couple of different types of incontinence, but in general, losing urine when you are not intentionally wanting to lose the urine.

Deborah Howell (Host): And then what is stress incontinence?

Amanda Phelps-Jones: Stress incontinence is more of a structural phenomenon. So when you have the loss of urine with either coughing, laughing, sneezing, exercise, those types of activities, when you've got the downward pressure from your abdominal cavity, pushing on your bladder, and then your pelvic floor muscles are not quite strong enough to stop that flow of urine, the urine then will escape and then you experience the loss of urine.

Deborah Howell (Host): Sure. And while we're doing definitions, what is urgency?

Amanda Phelps-Jones: With urgency, you experience a significant urge to get to the bathroom, as in if you don't make it to the bathroom, you will have an accident. And these women know where every bathroom is at every shopping store that they go to. When they're at the grocery store, they know where every place is that has a bathroom and where that bathroom is before they even start shopping. And sometimes they will also go to the bathroom just in case, which then creates other issues down the road and then we have to deal with that phenomenon as well.

Deborah Howell (Host): And they probably have pre-memorized the code to each bathroom door, right?

Amanda Phelps-Jones: You got it. Yes.

Deborah Howell (Host): Now, is urgency and overactive bladder the same thing?

Amanda Phelps-Jones: They're not the same thing, but they often go hand in hand. With overactive bladder, the key component there is frequency of urination. It's not uncommon for us to go to the bathroom every, you know, three to four hours per day. However, with overactive bladder, every two to three hours, it can be acceptable. However, with overactive bladder, you'll find people are going to the bathroom at least every hour, if not more frequent and they often have that sense of urgency associated with it. And when they go, they don't always feel as though they have completely emptied their bladder because their bladder gives them that signal to their brain that they need to go again, regardless of the fact that there isn't a full bladder there for them to empty. So it's basically a constant sense of needing to go to the bathroom. And then it's essentially like your bladder training yourself, like your potty training. Like I have three-year-old twins and I'm currently potty training them, and so it's kind of that concept. You're going all of the time. And so your body and your brain communicate to each other, your bladder and your brain communicate, and so they essentially get used to that. And your bladder is not used to holding an excessive amount of urine or appropriate amount of urine even. So you aren't able to hold an appropriate amount of urine after so long, so then the frequency becomes your norm and so overactive bladder becomes quite normal essentially. And then the urgency becomes part of it because once you get more of a volume in the bladder, you're unable to tolerate it. So that's why the urgency often goes along with it.

Deborah Howell (Host): I see. So as a hiker, I was always taught, you know, never pass up a bathroom. But really if you don't have to go, you should not do that because of what you just said.

Amanda Phelps-Jones: Exactly. Yes. It's not good practice.

Deborah Howell (Host): Interesting. All right. I'm going to have to change some habits here.

Amanda Phelps-Jones: Yes. Yes.

Deborah Howell (Host): Now, how can I tell if I have urgency incontinence or stress incontinence?

Amanda Phelps-Jones: Well, as I alluded to earlier with stress incontinence, it's the loss of urine unintentionally when you have a downward pressure being applied to your abdomen, which then of course pushes on your bladder, so the coughing, laughing, sneezing, exercising, that type of thing. With urge incontinence, you're losing urine on the way to the bathroom, so with urgency. Oftentimes, you'll hear it called turnkey incontinence. So when women pull into the driveway, they get their keys out of the ignition and put them in the door to get in the house, they often leak urine or have that sudden sense of urgency to go and they can't make it to the bathroom, so that's when they leak urine.

You will sometimes find too that when they get out of bed in the morning and first put their feet on the ground, they have that significant sense of urgency to go to the bathroom and that's associated with urge incontinence. The two different phenomenons being the way that we treat them, they are not one and the same. So it is very important for us to be able to differentiate the two. If you present to us, we will absolutely ask you all the appropriate questions. Your job is to just let us know that you're leaking urine.

Deborah Howell (Host): Absolutely. And is there anything to temperature change, like you go from a cold car or a cold outside walk and then you come inside and have an urge?

Amanda Phelps-Jones: I do feel like some women do experience that and I would say more so post-menopausal women, especially when there isn't always the same amount of estrogen on board as there is when somebody is in their childbearing years, because you don't have that same pelvic floor support that you had when you were circulating enough estrogen. I absolutely think that can be a part of it.

Deborah Howell (Host): And what causes urinary incontinence?

Amanda Phelps-Jones: There can be a multitude of things. Unfortunately, a little bit of weight gain. And as women, we tend to hold onto weight in our midsection and in our abdomen, so that can put more pressure on our bladders, which then can encourage the unintentional weight loss. So there's research indicating that even a small 5% to 10% loss of total body weight can improve incontinence.

Also poor pelvic tone and poor pelvic health, so having children can absolutely cause the incontinence or contribute to it. It doesn't mean just because you have children, you're going to have incontinence, but there's a couple of different factors that go along with it. The type of delivery that you have, if there's Excessive tearing with the delivery, if there's instrumentation with the delivery, like vacuum or forceps, if the baby's rather large, if there's complications with the delivery.

Then once women get into post-menopausal years, when they lose that hormonal influence of the estrogen, because it's really important to have that influence of estrogen on your pelvic floor. It's vital actually. God takes it away from us for a reason to help protect us from harmful things, you know, but it's actually very important to help keep your pelvic floor in good shape. So when it's not there, you do notice a thinning of the vaginal tissue and it also affects the bladder as well. So it causes us not to be able to tolerate bladder irritant products as we used to, so caffeine-based products, carbonated products, those types of things. So it will tend to encourage us to have overactive bladder and incontinence as well because of the lack of estrogen in addition to consuming the irritant products to your bladder.

Deborah Howell (Host): Good to know. Can I ask the same question? What causes stress incontinence?

Amanda Phelps-Jones: Well, as with the urge incontinence, the weight gain in your abdomen, of course, pushing down on your bladder as well as prolonged issues that can lead to those pressures in your abdomen. So people that may have chronic constipation or a chronic cough for whatever reason, so asthma or someone with COPD or a history of smoking, those kinds of things, the stress incontinence component often comes along with it, not just having children, but it can leak on your pelvic floor muscles. And then if someone has had a hysterectomy, even if they only take the uterus out and don't take all of the reproductive system, your pelvic floor will lose some of that support mechanism that the uterus provides. So it then allows the laxity of the pelvic floor at times. And over time, it's not an instant thing, but over time, can cause women to experience the leakage of urine.

Deborah Howell (Host): Interesting. Can you tell us about some of the treatments for urinary incontinence?

Amanda Phelps-Jones: Sure. With stress incontinence, as we've discussed previously in the conversation with stress incontinence, it's more of a structural issue. So with that phenomenon, as we said, there's more of the pressure going down on the abdomen. So we need to treat that component first. If that would continue following the treatment, your treatment is essentially not going to be near as effective as what it would be if you did not fix that original components, so i.e., asthma, it needs to be well controlled to your best ability. Obviously, that's something that you can't obviously control as well as other things.

Constipation is key. You have got to get constipation well-controlled and it also affects the urge incontinence as well. Bladders and bowels, they run on the same nerve pathways. So it's very, very important to keep bowel health in check when you're talking about incontinence. So, you would treat the underlying condition and then address the type of incontinence. So with stress incontinence, pelvic floor physical therapy is one of the mainstays of any type of incontinence. It's the common denominator. It actually is one of the most effective treatments for incontinence because they can take those muscles and essentially strengthen them by manual work and get them to function more appropriately and teach you how to use them more effectively.

It works for both types of incontinence. But with stress incontinence specifically, if you don't get the response that you desire from the pelvic floor physical therapy component, then you would need more of a structural fix because it is more of a structural type of incontinence. So that's where things come into play as a pessary, which would be a silicone device. It's more of a disc-shaped device with a knob on it that we insert in the office and it puts gentle counterpressure against bladder neck. So when someone would cough down and have that downward pressure, that little device is going to provide that counter pressure that you need to stop that flow of urine from escaping. So in essence, it would provide you the support that you need that your pelvic floor muscles aren't doing for you because they don't have the ability to do. And then ultimately, you could do a surgical procedure. And that's where you may have heard of things called a sling or a bladder tuck or a TVT, which is the other type of sling, but it's one of the slings that they use to fix the stress incontinence. But it's one of the more "permanent fixes" so that's ultimately what someone would prefer to do if they aren't wanting to do the more conservative treatment.

Deborah Howell (Host): Interesting. This is also fascinating. And you've covered a lot of this, Amanda, but what are some treatments for stress incontinence?

Amanda Phelps-Jones: With stress incontinence, it's more of the structural components. So it's the pelvic floor physical therapy, pessary use where they insert a pessary. We actually put that in the office. It's an office procedure, very easy management, as well as ultimately a surgical procedure that can help with stopping that flow of urine unintentionally.

Deborah Howell (Host): Got it. And finally, a little bit more about the treatments for urge incontinence.

Amanda Phelps-Jones: Yes. With urgent incontinence, it's more of a phenomenon where your brain and your bladder aren't communicating as well to each other. So structural fixes are not going to provide you the relief that you're looking for. The pelvic floor physical therapy is going to offer the support the way that it does with stress incontinence, because it's going to help strengthen your pelvic floor and they are going to help teach you how to properly use your pelvic floor. In addition to that, as a nurse practitioner, I can provide you assistance by prescribing medications that are going to help control the urgency and the frequency, the leaking in the middle of the night, that type of thing, getting up at night, as well as encouraging you to cut back on bladder irritants and losing weight, that type of thing. But primarily, it's medication management.

We do follow an overactive bladder care pathway when we're treating urge incontinence, which is often associated as we discussed earlier with overactive bladder. So we trial medications for a short period of time. If one medication doesn't work, we go to the next medication. If it doesn't work, then we go on to third line therapies, which would include more invasive approaches, that work on a neurologic level versus the medications. So there's neurostimulators that we can put in. Then we have surgeons that do that for us here in the office, as well as bladder Botox that is done here in the office as well.

Deborah Howell (Host): Absolutely incredible. I had no idea there were so many treatment options. Do I need a referral to make an appointment with you?

Amanda Phelps-Jones: Not to see a nurse practitioner in the state of Indiana. You're free to make a self-referral as well if you were seeing your primary care provider. I strongly encourage you to to discuss with them your concerns about urinary incontinence, because they can initiate that referral if you choose. But if not, you can absolutely call our office and ask to see me.

Deborah Howell (Host): This is such excellent information, Amanda, and gives hopefully a lot of people a lot of hope. Thanks so much for being with us today and answering some of our questions about incontinence.

Amanda Phelps-Jones: Yeah. Thank you for having me. I appreciate the opportunity.

Deborah Howell (Host): Our pleasure. This is Deaconess, the Women's Hospital, a place for all your life. For more information, visit deaconess.com/pelvichealth or call (812) 858-5950. Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women's Hospital podcasts. And for more health tips and updates, follow us on your social channels.

This is Deborah Howell. Thanks for listening and have yourself a great day.