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016: What you NEED to know about SUI

Stress urinary incontinence, or SUI, is one of the most common types of bladder issues that women face, but there’s a lot of confusion about what it is, what causes it and how to treat it. In today’s episode, Meredith Wasserman, medical doctor and a fellow in female pelvic medicine and reconstructive surgery in the Department of Urology at NYU Langone Health in New York City, sets the record straight about SUI and offers important guidance for those who are facing the condition.



Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America’s leading advocate for people with bladder and bowel conditions, with resources, connections to doctors and a welcoming community of patients, physicians and caregivers, all available at NAFC.org.

Welcome back to another episode of Life Without Leaks. I’m your host, Bruce Kassover and joining us today is Steve Gregg, the Executive Director for the National Association for Confidence. Welcome, Steve.

Steve Gregg: Thanks, Bruce. Great to be here today.

Bruce Kassover: Joining us today is Meredith Wasserman. She’s a medical doctor and a fellow in female pelvic medicine and reconstructive surgery in the Department of Urology at NYU Langone Health in New York City. So welcome Dr. Wasserman. Thank you for joining us.

Dr. Wasserman: Hi, Bruce. Thank you for having me. It’s great to be here.

Bruce Kassover: I understand that there are a couple of major categories of incontinence that you have particular expertise in, and one of the ones we very frequently hear about is stress incontinence. So can you tell us a little bit about what stress incontinence is and how you can identify it?

Dr. Wasserman: Sure. So urinary incontinence as a whole affects about 50% of the female population, and of those patients, about 50% will actually experience stress urinary incontinence. Stress incontinence is the type of leakage that occurs when there’s some type of stress on the pelvic floor. So what we typically will describe is coughing, laughing, sneezing, exercise, sometimes heavy lifting. And this may present as just a couple of drops, but it can also be something larger, like really losing the entire, you know, bladder’s worth of urine.

Bruce Kassover: So tell me, what are some of the risk factors for somebody who might be susceptible to stress urinary incontinence.

Dr. Wasserman: So, you know, a lot of what we hear about for stress incontinence is oftentimes women after they’ve had children, and that is certainly, pregnancy is certainly a risk factor. However, there are also risk factors for patients who have never had children before. Things like obesity, smoking, age and family history. We also know that menopause is a risk factor for stress incontinence along with other types of incontinence.

Bruce Kassover: And so somebody who starts experiencing some of these symptoms, I would imagine that for many people their first inclination isn’t necessarily let me run to the doctor and find out what’s going on, but they try to manage on their own. Maybe they try some products. If somebody’s starting to get the sense of, “Hey, maybe this is happening to me,” what do you recommend that they actually do?

Dr. Wasserman: Many patients can go online. There are lots of resources. So one of the first steps in treating stress urinary incontinence is usually pelvic floor muscle training. So this is training your pelvic floor muscles to try to increase the strength, to try to support the urinary tube, the urethra, to prevent leakage. There are lots of resources online and also there are apps on your phone.

There are lots of devices that can teach you how to engage those muscles and do exercises, what we call Kegel exercises, where you are squeezing the pelvic floor, similar to if you try to hold your pee while you’re urinating, that would be a Kegel exercise.

Bruce Kassover: I’m sure that there’s a lot of misinformation about stress incontinence as well. I mean, I would guess that that many people expect that this is the sort of thing that happens only to an older population or mostly to an older population. You did mention menopause is one of the risk factors, but is that so, or is this something that younger people can experience as well?

Dr. Wasserman: Stress incontinence is the type of incontinence that we often see starting in a younger population, more so than urgency urinary incontinence, which is another type of incontinence we can talk about. For these patients. It’s often younger women in their thirties, forties, fifties. Certainly the rate of stress incontinence will go up as women approach menopause in terms of the number of patients we’re seeing with stress incontinence, but it’s a type of incontinence that can start quite early even, we may see it, you know, after a woman delivers her first child, you can start to see stress incontinence or even someone who’s younger, maybe a heavy smoker, coughing a lot, or obese, you can see some leakage.

Bruce Kassover: Okay, I That makes sense. Now, one of the things when it comes to seeking help, as a woman who’s practicing medicine, do you find that women often don’t advocate for themselves as vigorously as they ought to, that there, there’s either a sense of shame or just reluctance or, you know, other things that are holding them back from really getting the treatment that they deserve?

Dr. Wasserman: Absolutely. And I think it’s not just women, I think it’s men and women, anybody dealing with incontinence, urinary leakage, you know urinary issues are certainly very taboo to talk about. It’s very private. And also to accept that you have an issue with urination, something that we, you know, take for granted as a faculty that we can control our entire lives and all of a sudden you can’t control it. It can be something that’s very hard to come to terms with and therefore really hard to seek help with. I think certainly there’s always a dynamic of a female patient may not be comfortable talking to a male provider or a male patient may not be comfortable talking to a female provider, and I think the best thing that a patient can do is to try to feel comfortable, which is easier said than done.

Find a provider that you feel comfortable with and if you know patients feel like they’re just not ready to talk about it or feel like they don’t trust that they’ll bring it up in an appointment, I would recommend trying to bring someone you trust with you to your appointment, whether it’s a spouse or a partner or a friend who will hold you accountable to ask for help.

And the other thing that I would recommend is to try writing it down. We have plenty of patients that come into the office with a sheet of their concerns, and it just takes the burden off of you to have to verbalize and prompt the concern you have. It’s right there on a piece of paper. Your doctor can look down and say, “Hey, I see you have some concerns with urinary leakage. Tell me a little bit more about that.” And that may take a little bit of the burden off of you as the patient to feel like you have to be brave and kind of pull it out of nowhere and talk to your doctor about it.

Bruce Kassover: I’m so glad you talked about writing it down, because that’s one of the things that we’re really, really big advocates for. People who, and this is our shameless plug, is that people who visit NAFC.org can find things like bladder diaries that they can download for free so that they can keep track of their symptoms and discussion guides that talk more specifically about not just some of the things that they can expect to happen in a physician encounter, but also offer some questions and advice to help them open up about the symptoms they’re going through.

And I know that, you know, for a lot of people this sounds like homework though. It’s like, “Oh my God, I have to get on a piece of paper and keep track of things.” Can you tell us a little bit more about bladder diaries and the value that they offer and why people really do get some benefit from them?

Dr. Wasserman: I love bladder diaries. I think they’re fantastic. I don’t think you’ll find a doctor or a urologist or urogynecologist that doesn’t like them. You know, I think it’s really important for you as a patient to understand your symptoms to better advocate for yourself. Unfortunately, with the way that medicine is now, we really are limited in the time that we can spend with patients.

And so for a patient to come in with an explanation of what’s going on really does benefit us. So specifically what avoiding diary is, is this is usually a log that you’ll keep anywhere from one to three days. We usually recommend patients do it, ideally on a time that they’re not going to be kind of out doing some crazy activities.

Do it on a time that you’re, you know, going about your normal routine. And you’ll keep track of things that you’re drinking, types of beverages you’re having and how much, and then how often you’re going to the bathroom, how often you’re leaking, when you have urgency. There’s lots of different types of voiding diaries out there, and you may fill out one type if you see a urologist or urogynecologist, or you may fill out another type if you see a pelvic floor or physical therapist.

But ultimately what we’re trying to understand is, what’s going in, what’s coming out, and what kind of symptoms are you having in relation so we can try to better understand what’s going on and help diagnose.

Bruce Kassover: You know, you mentioned something that I did want to touch on a little bit more. You talked about physical therapists, urologists, urogynecologists… there is a whole universe of specialists out there who can help, but I also believe, if I’m not mistaken, that there aren’t nearly as many of them as we’d like to have. This is a pretty significant problem. What are your thoughts on how a patient might want to consider where they go and who they look for when they, they’re experiencing symptoms?

Dr. Wasserman: A great place to start is to speak with your primary care provider or a gynecologist. Some may be comfortable starting treatment or at least be able to guide you, and others may refer you. There are lots of different people you can see. I would say the main categories or kind of types you can see are urologists and urogynecologists.

Urogynecologists are gynecologists who have done a specialized training like what I’m doing now to specialize in urologic issues related to, kind of, the gynecologic system, and urologists, although trained in urologic issues, voiding dysfunction, things like this, can do special training, which is actually what I’m doing. I was trained as a urologist. I’m doing extra training in female pelvic reconstruction and urinary symptoms, and, so, this kind of point is a place where a urologists and urogynecologists kind of meet. It’s very confusing.

And then to kind of add to the mix, there are pelvic floor physical therapists, which are physical therapists that we will refer patients to that have trained as physical therapists and have actually done additional training to specialize in the pelvic floor, and they help us a lot in helping patients, you know, manage their symptoms, learn exercises to control their symptoms, specifically urinary, they can also help a lot with pelvic pain.

So all of that is to say you would be perfectly fine seeing a urologist, a urogynecologist, or they’re a urologist who specialize in female pelvic medicine and reconstructive surgery or FPMRS. Any of the three would be someone who can help you, who has done specialized training in urinary dysfunction and leakage.

Bruce Kassover: So you finally had enough. It took a while, but you’ve made the decision that you can’t live like this anymore and you’re ready to see a physician. You think it’d be easy to find somebody who could help, right? Not so fast. Finding a qualified provider is not like picking a plumber from the Yellow Pages. You want somebody who really knows their stuff.

The good news is NAFC has a Doctor Finder right online, so you can find a specialist that you can count on. It’s free, too. Just visit NAFC.org, hit the resources button the top, and choose Doctor Finder. That’s NAFC.org, then the resources button at the top, and choose Doctor Finder. It’s the single most important thing you can do to put yourself on the road to a life without leaks.

Steve Gregg: One of the issues that NAFC began to face early Dr. Wasserman was, you know, this mesh created by the FDA on mesh litigation. And so there are a lot of women, particularly SUI women, that don’t want to engage because they’re afraid the only solution is surgery. And we do know that it still remains the gold standard, so surgery is really viable. Can you address, sort of, the fear of surgery and, as a result of that, the lack of interest in talking to a doctor who they think the only answer is surgery.

Dr. Wasserman: I’m so glad you brought this up. So I’d like to first address the mesh comment and then I would love to talk about surgery and kind of fear of surgery in other ways.

So with regard to mesh and mesh litigation, this is something that we see all the time in our office. Patients come in, they’ve seen commercials from lawyers saying, “If you had mesh placed through the vagina, please call this number. You may, you know, have been a victim of malpractice.”

The FDA did pull a specific type of mesh that is used through the vagina to help treat vaginal prolapse. That is a different issue than stress incontinence, which we do still treat with mesh and is the gold standard. The mid urethral sling, which is a strip of surgical mesh that we place around the urinary tube or the urethra, it acts as a hammock to help support the urethra for patients with stress incontinence.

This has been used for 20, 30 years and has been proven over and over and over again to be safe for patients. So it’s important to understand that the mesh that is being described in the commercials with lawyers or you’re hearing radio ads, that is very different than the mesh that we place. So if that’s your main concern as a patient, I hope that that helps to clear things up a little bit.

That doesn’t change the fact that there are certainly patients who don’t want to have surgery, and there is nothing wrong with that. Yes, we are trained as surgeons. It doesn’t mean that we have to do surgery all the time. We have plenty of other tools in our arsenal to help for patients who are too concerned about having surgery or just not ready to take that step.

Things that we offer specifically for stress incontinence is what I mentioned before, which the pelvic floor muscle training, which you can do with a pelvic floor physical therapist, or you can do on your own at home. We also have vaginal inserts that can be used to help put, you know, mechanical pressure up onto the urethra.

These can be removed. They can be used on an as-needed basis. This is something that we would commonly recommend for women who have leakage. With very specific activities, say a trampoline workout class or when they go for a run, or maybe they’re a marathon runner and they only leak when they run long distances. These will be times you can use an insert and then you take it out when you don’t need it.

And we also offer bulking injections in the urethra. So these are, essentially, little fillers that we place in the urinary tube to help decrease the size of the tube on the inside to provide some resistance to urine.

And this is becoming more common. It was, we’ve been doing it for a long time. However, a newer material just came onto the market in 2020, had been used in Europe for a long time. We’re seeing a lot of success with this, and that’s a procedure that’s done in the office. So we certainly have other options besides surgery that patients can consider.

And it’s important to have that discussion with the provider you’re seeing so you can understand and decide what option is best for you.

Bruce Kassover: Outstanding. So before we go, one thing I wanted to ask you is for your single most important tip to lead a life without leaks.

Dr. Wasserman: I think the most important tip to live a life without leaks is to understand what your symptoms are and how they are affecting your life, and how they may or may not be changing your day-to-day life, because that’s going to help guide you in how we can make things better. But certainly, living a healthy lifestyle, avoid smoking, try to exercise and not, you know, put too much extra weight on the pelvic floor will help prevent leakage. But certainly understanding yourself and your body and when you are leaking, that gives us so much more information as a provider to be able to work with you and decide how can we make your life better? How can we give you a better quality of life and live a life without leaks, ideally, although it’s not guaranteed a hundred percent of the time, but at least make your life a little bit closer to how it was before.

Bruce Kassover: Well that’s awesome. Well, thank you Dr. Wasserman. We really appreciate you joining us and sharing all of your insight on stress incontinence, so thanks.

Dr. Wasserman: It’s my pleasure. Thank you for having me.

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin McLeod. More information about NAFC is available online at NAFC.org.

For more information about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram, Twitter and Pinterest.

Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License

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