Bladder Health and Longevity: What Your Symptoms Are Trying to Tell You

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we’ll get them corrected immediately. 

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 Sarah Jenkins, the Executive Director for the National Association for Continence. Welcome Sarah. 

Sarah Jenkins: Thanks, Bruce. I’m so happy to be here. 

Bruce Kassover: Me too. Today’s guest is Dr. Mia Duncan. She’s a dual board certified urologist and urogynecologist, and the founder of Columbus Urogynecology in Columbus, Ohio. That’s a consultative practice that’s focused on bladder health and continence across the lifespan, and that’s pretty important because that’s what we’re going to be talking about today is incontinence and longevity. So Dr. Duncan, thank you for joining us today. 

Dr. Duncan: Thank you for having me. It’s my honor to be here. 

Bruce Kassover: Now we are very interested in talking about the relationship between longevity and incontinence, but before we do, maybe you want to give us a little bit about your background. How did you get to be talking with us today?

Dr. Duncan: I’m the health policy scholar for SUFU, which is a division of American Urological Association. This division focuses on female urology, reconstructive operations, and in the process of being health policy scholar, Sarah and I have run into each other in our advocacy efforts, and so that’s what landed me here is our multiple meetups over last year advocating for pelvic health and bladder health awareness.

Bruce Kassover: That’s really interesting and it’s nice to hear that you have a relationship with Sarah and the National Association for Continence because we always like it when guests are familiar with our mission and what we’re trying to do, and we try and align ourselves.

So now today we want to talk about not just how incontinence affects you day to day, but how it affects you long term . Because I think that, and tell me if I’m just crazy here, a lot of people think of incontinence as a problem of immediacy. I have a leak that happens now, and that’s really the extent of it. If I can stop it, then things are great, but there’s really something else going on that really has an effect that lasts much longer. Maybe you could talk a little bit about that for us. 

Dr. Duncan: I’d be happy to . One of my passions is looking at bladder and pelvic health through a longevity lens, because I do think that especially when someone is suffering with leakage, it’s a very distracting symptom, leaking, and it can take, takeover the narrative, and by the time people get to see the doctor, they’re just like, “Man, make this go away. This is awful.” And the root cause conversation and the bigger picture can sometimes get blurred, but usually there’s a fair bit of runway before you got to that point of leakage, and there’s a lot going on underneath the surface of that leakage.

And aside from the fact that leakage by itself is incredibly bothersome in every. Possible way that I think we could all collectively think of, it often is also a sign of other things going on in the body that are important with respects to your health span. And that’s just like how long you live in good enough shape to climbs, climb stairs, feel good and go on vacations and just general longevity. 

Bruce Kassover: Do you mean that, for example, if I’m experiencing incontinence of some form, that may actually be a sign that there’s something else, something perhaps more troubling going on in my body as well? 

Dr. Duncan: Absolutely . And I’ll roll back just a little bit here and share with you both that I view incontinence as a little bit, sort-of the tip of the iceberg. It’s the thing that usually gets people’s attention. They’ll put up with a lot of things for a long time before they end up in the office in front of me or my colleagues complaining about things because it’s the leakage that kind of sends them over, if that makes sense.

So when I talk about longevity and leakage, know that I’m really almost taking it back a step to talk about just longevity and even early bladder signals with respect to your health. I view the incontinence as further down that pathway, if that makes sense. 

Bruce Kassover: It does make sense. And so if that is the case , what sort of conditions do you see incontinence is associated with that people might want to be, concerned about or at least proactive about?

Dr. Duncan: I think that every large problem begins small, and we could apply that viewpoint to a lot of the things that we deal with in life. And bladder signals, early mild symptoms, start to come up in childhood and even as little children. Not for everybody, but that is definitely where some of that can first show up.

It can even be in the twenties. And because anything bladder related, especially leakage is associated pretty strongly with things like getting older or being in menopause, things like that. Some of the early signs that something is amiss with the pelvic and bladder health just get dismissed.

And, in fact, younger people may even be told, “Hey, you’re too young to have a problem,” or they might be told that they’re going to grow out of it. And, in fact, I see those people as adults and they never did grow out of it. And everyone’s bladder has a different story. Sometimes that narrative starts younger and sometimes it starts later.

But either way, everything doesn’t typically start with flooding, awful leakage, like what some women end up dealing with. And it’s a real passion of mine to open that conversation much earlier than full-blown leakage and look at it in more like a spectrum of symptoms. Because no matter where you are in that journey, it can tell you something about your health.

Bruce Kassover: Now I am wondering when we’re talking about this that people will now think that, “Oh my God, I have leaks. That means that I also have some terrible condition, something horrible that’s going to, you know what? The clock is ticking.” But can you reassure them or maybe not reassure them? What do you say to somebody who’s worried like that ? 

Dr. Duncan: Unfortunately the clock is ticking for all of us. And that’s everything with respects to our health. But everything isn’t as one-and-done as, “Oh, you’re older, this is it.” It’s completely fatalistic. I don’t think that at all.

It’s never too early to have a discussion of bladder health, and it’s never too late, either. So let me say that. And when I talk about bladder signals, why I call them ‘signals’ is they can be just general nudges and messages. They are not necessarily saying, “Oh my God, you have cancer,” or, “Oh my god, you have some serious problem with your health.”

They’re little nudges, little messages that you can pay attention to, to learn a little bit more about your health. And it doesn’t necessarily have to be a bad thing. And, in fact, some of those messages, if we tune in, might even be really. Easy things to listen to and process. Like for instance, having low vaginal estrogen, that can lead to a little bit of bladder irritation and a little bit of even burning with urination just from having low hormones.

And so I think most people aren’t scared of that, right? So that’s as an example of a signal that your bladder or your urethra might be giving you to tune in. And the answer to what’s causing that might just be something simple like low vaginal estrogen, if that makes sense. 

Bruce Kassover: It does make sense, and I certainly hope that for everybody it is something simple. So somebody comes into your office and they’ve been having a leaking issue. They’re brave enough to make an appointment and see you and talk about it, which is also a big challenge. But they do that. How do you get to the bottom of things and really figure out what’s going on once they’re there in front of you?

Dr. Duncan: I love this part. So this is the root cause exploration, which I’m really enjoying in my consultative practice. And I use a tool called a bladder diary. Now of course you get a health history, you want to understand their symptoms and you want to do a physical exam, which really must include a pelvic exam.

I must say that, because there are so many people who have been to two, three urologists and they’ve never had a pelvic exam and that can’t be when we’re talking about bladder leaks, okay?

But the part that I think is really fun and really informative is when we move into the evaluation using a bladder diary. A bladder diary is just simply a tool that you take home with you, with a little device to measure your urine and a little sheet that you record what you drink and what you pee, and you specifically measure your pee and write down ounces or milliliters of what you drink for a couple of days.

I take, the history I take, the exam that I have done in the office, and then I pair that with review of that bladder diary to see if I can understand what is going on with their bladder leakage. And I find that this is not only very helpful for me; it’s helpful for the women that I see and take care of – and some men that I’ve taken care of over the years – to really see what’s going on.

And instead of just guessing at the symptoms, we can actually look at that data together and come up with a hypothesis as to why we think the leakage is happening. Because as you all probably know, there are multiple different causes of leakage, and helping identify what kind of leakage a person has can really help guide the therapeutic options that you give them.

Bruce Kassover: So that makes me think. If you have somebody who comes to you, and you go through the diagnostic process, and you think that there may be something additional going on that’s related to, that’s causing the leakage, do you then partner with another specialist? Do you take it on yourself? How does that work? 

Dr. Duncan: When you say something else causing a leakage, do you mean a medical issue causing the leakage or can you just expand on that a little bit for me? 

Bruce Kassover: Actually that’s a good point. Aside from medical issues, what else might there be that would be causing leakage that you’d be able to address?

Dr. Duncan: To the person experiencing leakage, it seems so simple. I’m leaking, fix it, but the etiology, or the cause, of the leakage has a fairly long list. It could be that the person isn’t emptying their bladder and that can be from nerve issues, pelvic floor issues. It can be from scar tissue blockage along their urethra tube. So it’s literally getting away in the way of the person emptying their bladder.

It can be diagnosis like vaginal prolapse where descent and loss of support of the pelvic floor pushes on the urethra creates a little bit of kinking, and the person can’t get their urine out of their bladder, and so the urine never completely empties… the person’s prone to leakage, so that’s urinary retention or incomplete emptying.

Other causes of leakage include bladder overactivity, that’s a huge one. And that one can be subtle. But overactive bladder is simply just, you get an urge and you leak before you get to the bathroom. And I call it you go from zero to a hundred… instead of thinking, “Oh, I have an urge and I’m going to head off to the bathroom,” and you saunter over to the bathroom, this is this really fast pressure and urgency that happens that starts small and escalates to a really strong signal before you can get your pants down and go pee. And so sometimes people are leaking on the way to the bathroom, and sometimes the bladder just goes spontaneously. It just squeezes and expels urine out of your body without any warning. That’s also overactive bladder, but sometimes if the nerves aren’t working correctly, the person doesn’t even feel an urgency. It just comes out. It’s maddening for them. And sometimes it’s your more-commonly-spoken-of stress incontinence, and this is the one that comes up a little bit more often. I think people feel comfortable talking about this one socially. The little leaks on a trampoline playing sports, jogging. I think that one has become a little bit more socially acceptable to talk about. And that one is just stress incontinence and sometimes people have a mix of several of those things going on.

Sometimes the body is making fluid at a very fast rate because of the fluid choices a person is making. For instance, alcohol is a diuretic, so is caffeine. Sometimes medical conditions and medications people take for medical conditions like Lasix is a great example. People take medications to help promote more urine production to get rid of extra fluid on their body. Those people are more likely to suffer from leakage because of the rate at which they’re making urine, and that’s because of the Lasix they’re taking.

And then medical conditions. For example, sometimes people, their legs are swollen in the day. Let’s just say their veins aren’t working properly when they lay down at night. The body reabsorbs that fluid and is, “Aa ah, it’s so much easier to send all of that fluid back up to the heart. The person isn’t standing, I’m not working against gravity.” And the person while they’re sleeping, literally physically makes more urine because of that circulatory improvement.

And so it could just be as simple as that why the person has leakage at night or gets up at night, or, this is a huge one I hear about from people and it’s the, “Oh my God, every morning when I wake up, I cannot make it to the bathroom.” And a lot of times those people are simply just making more urine overnight. It’s not necessarily all the fault of their bladder.

So instead of just saying, that’s leakage, let’s get rid of it. I’m looking at your medications, your anatomy, I’m making sure you empty your bladder. And we’re on the diary I just spoke of, we’re looking at the urine production overnight. Is the bladder just over full?

Those are things that we can intervene on without major surgeries or even medications sometimes. And a lot of times people don’t realize how simple it can be. 

Bruce Kassover: Simple? I like The thing I don’t like is how many different things can be generating all of these symptoms. Yeah. And I’m guessing though that the thinking about that list that you just went through is that it does sound like a good deal of them are the sorts of things that can be dealt with directly with your urologist or urogynecologist. Is that, that fair to say? 

Dr. Duncan: Absolutely . And when people, if anyone ever feels like, “Oh my goodness, there can be so many different things wrong.” I view that as a good thing. Here’s why: it gives us a little bit of nuance, a little bit of opportunity, versus, “There’s one thing wrong and we have one solution.”

It becomes all or nothing. When we have multiple different potential contributors, we can really put our detective hat on and sleuth real causes for people. And I’ve dealt with people that have seen 3, 4, 5 urologists or urogynecologists and they’ve had two slings and Botox and all of these things and nothing’s worked.

And I have found out that they’re drinking six or seven liters of water a day. Really simple stuff where all it was behavioral management and that got missed along the way in their journey. So that’s not scary at all. That’s a simple, “Hey, why are you drinking this much water? Is it dry mouth? What is it? Just habit?” There’s a lot of pressure in social media to drink more water, and people do that for various reasons because they’re trying to be health conscious and they don’t realize how it could be hurting their bladder. And that’s one of the most satisfying and easy fixes that I end up having the pleasure of doing in my practice.

Bruce Kassover: Yeah. There really is this thing that’s going on where people feel like they have to walk around with giant buckets of water all day long and there’s a sense of you have to be hydrated I think people may take that a little bit more extreme than it needs to be.

Dr. Duncan: You’re saying that perfectly. And I actually, my whole office at, before I went out on my own, would laugh at me because I would tease the whole Stanley Cup culture, the giant pink Stanley Cup, and they’re very cute. But they are huge. And when I see people come into my office with a big Stanley Cup, I already know that’s probably going to be part of the problem. To your point, Bruce. It’s never… I also try to keep in mind it’s not just one thing, and I’m certainly not trying to blame people. I’m doing the exploration with them and looking at that amount of water. And I’ll tell you, there’s a couple of health conditions where I see this a lot.

One of them is MS. Okay? And MS patients, as you probably know, suffer from incontinence quite a bit. But the number one thing, at least one of the top things they get told by their neurologist, is “hydrate, drink lots of water.” Same with people who have low kidney function. And I don’t know about you guys, but if I have MS and there’s not that many things I can do myself personally, beyond take the meds they’ve given me, but they’re asking me to hydrate, I’m hydrating. Like you’re going to hydrate, right? Because if that’s what stands between you and your next flare of multiple sclerosis, you’re going to do that. Same with kidney health. And really, I’ve seen a lot of people with MS on accident drive a bit of that dysfunction in their own bladder where they just don’t know that they’re overdoing it.

And teasing that apart is extremely satisfying because, a lot of times people with neurological conditions that affect their bladder, nobody looks further. The root cause is assumed to be the spinal cord injury. The root cause is assumed to be MS. And while we can’t lose sight of that being part of the picture, we can’t stop thinking about what else, because I’ve listed many different things that can contribute in our conversation so far.

And so we want to look at their fluids. And I have actually seen people consuming so many fluids that they’re not only incontinent, I find out they’re unable to empty their bladder once we normalize their fluid patterns to just two liters a day, and I’m not talking about dehydrating people. Simply drinking normal volumes of fluid, we often see a rapid correction of the bladder dysfunction.

So again, everything doesn’t have to be bad. Your bladder signal there is saying, “Hey, too much of a good thing!” I t’s not saying something scary; it’s just saying that you’re drinking too much water. 

Bruce Kassover: That’s encouraging to hear. But let’s talk about some of those conditions that either contribute to longevity issues or just chronic things in particular. One that I know that our listeners are always very interested in is urinary tract infections, particularly people who have chronic UTIs. And can you talk about the relationship between those and incontinence? 

Dr. Duncan: Yeah, I can . Chronic UTIs are another mixed bag, like you were just asking me about incontinence and I talked about multiple different causes and nuances behind the incontinence, and UTIs collectively are another catch bag area where we have a lot of mimics and then we have the real thing.

And most people that have, significant incontinence who are also dealing with UTIs are probably peri- or postmenopausal. I’m not saying there’s not exceptions. There’s certainly exceptions, but in this context, many times these women are not getting vaginal estrogen cream or suppositories to help boost their normal healthy vaginal bacteria because local estrogen, meaning cream that you literally apply here to the vagina, helps create a healthy bacterial environment in the vagina, which then protects the bladder from UTIs.

So a lot of times the correlation isn’t so much that incontinence is causing the UTIs, but that sometimes the other coexisting conditions have not been properly managed or treated. And this is what I meant earlier when I was talking about incontinence and leakage being very understandably distracting.

But sometimes there’s these little things that lurk underneath the incontinence, which is just simply vaginal estrogen replacement. That is a quick fix to resolving UTIs. It gets a little more complicated because low vaginal estrogen can also cause a feeling of UTI when a person doesn’t have one.

What that means is you can have burning with urination and bladder irritation and have a urine culture be negative, and that is because the low vaginal estrogen is causing the UTI symptom. There are other mimics like having a vaginal infection. If a person takes antibiotics for UTI and gets bacterial vaginosis or a yeast infection, that vaginal infection or vaginitis can cause burning with urination and bladder irritation because these are close neighbors with very thin walls.

So what’s happening in the vagina affects the bladder and they don’t exist separate from one another. And I guess, finally, this is really important and that is that the clean catch urine samples that people give their doctor when they think they have a UTI, you are peeing through an opening that is part of the vaginal opening, and again, these openings are really close, the urethra and the vaginal opening. And so we pick up on vaginal white cells and bacteria living in the vagina and wash that into the cup because low vaginal estrogen can lead to e. coli and other bacteria from the butt area living within the vagina or around the vaginal opening, you can even get a culture that says a hundred thousand e. coli with the source not being from your urine, it’s actually coming from your vagina. And that comes from not being on vaginal estrogen. That is not a hygiene issue. That is not a hygiene issue. UTIs are not typically a hygiene issue. This is just a change in the vaginal pH that occurs with menopause.

And these are really simple fixes for people. And if you fix the vaginal estrogen, usually the bladder feels better. And I’m not going to say it cures leakage, but oftentimes the leakage improves, and certainly UTIs don’t help leakage. So if the person is having some real UTIs, not any of the mimics we just discussed, using vaginal estrogen is going to help them with that aspect of their health as well. So less UTIs, probably less leakage. Again, I’m not marketing it as a cure, I’m just saying it’s a piece of the pie.

Sarah Jenkins: I think That’s a really important point and one that a lot of our listeners probably haven’t heard before, using vaginal estrogen to help prevent UTIs. One question that I know probably a lot of people have, and I’m sure you’ve heard it, is this question around safety and how safe is vaginal estrogen. We’ve heard all of these different things over the years about how estrogen can be risky for women. Could you just weigh in and share your opinions on that?

Dr. Duncan: That’s a great question, Sarah. I think that the fear behind use of estrogen has really harmed women because estrogen just got put into one big bucket. Okay? And it was really scary there for a while. I remember when the Women’s Health Initiative first said it was going to cause cancer, and everyone’s, “I don’t want cancer.” But even now, in the excitement of the black box warning for estrogen coming down and it being a bit more normalized, you see a lot of it on social media, we’re not talking about the difference between systemic hormone replacement and vaginal hormone replacement. And Sarah, that’s absolutely central to answering this question because systemic hormone replacement is when you’re using a patch or a pill or some form of estrogen and/or progesterone that is systemic. It goes through your whole body. When we’re talking about using estrogen cream, we’re literally applying it to the vaginal opening here. Okay? Or we’re putting a tube inside the vagina here and deploying a cream or a tablet to deliver estrogen to the vagina. That’s local replacement. It’s targeted replacement of estrogen to the area that desperately needs it.

So I call that giving her a drink, because that really helps the health of the vagina in terms of the good bacteria versus, say, the bad bacteria. It creates an environment with more lactobacillus and e. coli don’t like living in that environment, and so it acts like a probiotic.

Probiotics over the counter or pedaled online, they don’t have any good studies that show effectiveness, whereas estrogen cream does. And we know that estrogen cream promotes healthy lactobacillus and it’s not systemic. So let’s say that you have a high risk of, let’s say that you’ve had breast cancer, you can safely use estrogen cream.

And I’ve had people terrified, okay, to use estrogen cream. And I get it, you’ve had breast cancer and now I’m going to come along and try to talk to you about estrogen cream. Rightfully, they’re scared, and there’s an emotional element, too, because they want to live and there’s, they’re in survivorship mode, but now they’re dealing with their vagina feels like it’s on fire, or they’re dealing with UTIs, or it hurts to urinate and it’s all hormonal, low hormone related.

And I talk to those people about, okay let’s just use a little tiny, pea size on the vaginal opening, try it twice a week. We’re talking about, that is minuscule amounts of estrogen. And sometimes that’s all people need to feel better. And again, all of our studies support that this is not systemic. So the decision tree and algorithm for, should I use vaginal estrogen, is not at all the same for using systemic hormone, which is more for general wellness, bone health, cardiovascular health, hot flashes. Topical estrogen, or local estrogen applied directly to the vagina through a tablet, a ring, or a cream is not going to help you with your hot flashes, your bone health or your cardiovascular health. It’s meant to stay and live in that area. And you can use estrogen cream vaginally when a person is a child. Sometimes little girls get labial adhesions, and we use it on those. You can use it in breastfeeding women because their vaginal estrogen is low when they’re lactating and breastfeeding their child. You can use it in people who have birth control that’s causing low vaginal hormone issues or menopausal patients.

So there’s no cutoff like there is with systemic hormones to say, “Hey, you are, 65, so you can’t use the systemic hormone anymore.” That cutoff does not exist with topical hormones. And you can also start them earlier too. Again, it’s not, that one’s age agnostic, if you will. So it lowers that, like, friction and decision paralysis people feel with hormones because they’re just putting it on their vagina. And as soon as they can understand that it’s not systemic, we’re not increasing blood levels of estrogen, then they feel a lot better about it.

And for reference, your listeners can go to our very exciting American Urological Association guideline from 2025. We were thrilled to finally see that we have a guideline about how to deal with low vaginal estrogen. It’s called genitourinary syndrome of menopause. And if your listeners do any one thing today, it would be to learn about that, if they’re perimenopause or post menopause, genitourinary syndrome of menopause. And that guideline walks through what I’ve just talked about. And it can really change a life and not only change a life, it can save a life because UTIs do, they can be fatal.

And I don’t want to scare people, but a urinary infection most of the time is not going to be serious like that. But it can be. But the good news: totally preventable in most cases with a little bit of vaginal estrogen. 

Sarah Jenkins: Yeah, that’s great to hear. And such a… I don’t want to say ‘easy,’ a simple fix for people who are really struggling with that. It’s just a great, great tip to know. 

Bruce Kassover: Now , Dr. Duncan, that also got me thinking maybe you could talk a little bit about the relationship, if there is one, between sexual activity and either UTIs or incontinence as well.

Dr. Duncan: Yes, I would love to. What happens when you’re having intercourse is it’s very easy to introduce pathogens or bacteria that we don’t want in the near urinary tract, from the vagina into the urinary tract. And even on this little model here the urethra seems like it’s distant, but in real life, the urethra is at 12 o’clock on the vaginal opening.

So it would live closer to the top here. And it is why women are prone to getting, urinary tract infections. And if our vaginal health isn’t good because we’re hormonally altered in some way, at any age, we’re lactating, we’re on birth control. And some versions of birth control, oral contraceptives can lower vaginal estrogen. It changes our vaginal health. And so because of the proximity of the vagina to the urethral opening, intercourse can act as a means of introducing bacteria into your own urinary tract.

Bruce Kassover: I suppose that in some cases the UTIs, the, and some of these other issues may go hand in hand. So if there is a relationship there, I certainly would like to hear about it. 

Dr. Duncan: The relationship is that people with significant incontinence tend to be, again, there’s exceptions, perimenopausal or postmenopausal and may have unmanaged vaginal estrogen at the same time as having incontinence, but the incontinence is getting all of the airtime when they’re with their provider and just in their own head space, which is understandable.

I think that the UTIs that we see in that case are likely due to, or more likely due to low vaginal estrogen. Even the studies that have looked at like pad products and things like that, it is more likely unrelated to pad products… but I’m not speaking to individual experience here. I’m just speaking to big picture and like data that we have. It’s more likely available to low vaginal estrogen or something being off about the vaginal health in terms of the good bacteria, that would be lactobacillus, versus bad bacteria. 

Bruce Kassover: Now let’s talk about some of the other things that might be long-term issues for people who are living with incontinence . In particular, I’m wondering about sleep disruption, especially if you have episodes at night that are waking you up. What is the long-term concern?

Dr. Duncan: In my experience, people with incontinence tend to be woken up more by bladder urgency versus they sleep through the leakage. If the bladder is, and I’m not saying there’s not exceptions to that either. Know that, I should say I, I don’t believe in speaking in absolutes because, everyone has their individual experience.

So what I’m sharing is what I’ve seen clinically and taking detailed histories over the 20 years I’ve been doing this, and the thing that disrupts people is the feeling that they need to go, that reaches into their sleep state, wakes them up and takes them to the bathroom. And the concern there, whether that’s occurring with leakage or without leakage, is that we disrupt that slow wave sleep, which is called deep sleep, and that sleep is critical to preventing dementia of all types. And also it’s important to get deep sleep in terms of just your psychiatric health, how your mood feels things like depression, anxiety, things like that.

Also, I should say that one of the first things to slip in brain changes related to like early dementia would be the deep sleep goes. So independent of these other things, deep sleep can change. And so the bladder is maybe more likely to wake you up at night. And so the two kind of feed on each other potentially. And I’m not saying that just because a person wakes up at night, that means they have dementia or will get dementia, but it certainly can have effects on the brain if that bladder leakage or urgency at night that is going unchecked is allowed to continue unchecked.

Bruce Kassover: That is certainly something to be aware of because if I’m thinking that my, my only issue is I have leaks, then that’s going to add a little bit of additional urgency, pardon the pun, to wanting to get treatment for.

Now you also talked about things like depression and an effect on the, on your mental state. I’m wondering, what are some of the long-term concerns about things like withdrawal, depression and other things that are related to incontinence that we see often go hand in hand?

Dr. Duncan: I want to I’m going to walk back from incontinence one more time and just say that a lot of times what’s waking people up is the urge to pee with or without leakage. So I don’t want to just even talk about just leakage. It’s both, it’s urgency with or without leakage or just being wet like you’ve said, or you wake up and you’re going already.

And the long-term risk of those kind of disruptions or even short term is… and I know that your team has data on this, but the data I’ve read is that it absolutely increases risk of depression. It even has been correlated with suicide. It’s serious. And I’ll make a little plug for the bladder diary again because that tool that we talked about early in our conversation is cheap. It’s easy. It’s underutilized. And it is a window into other things that are happening at night that we can do something about to get that person their sleep back regardless of their getting up with leaks or without leaks. 

Bruce Kassover: Yeah it’s not a surprise to hear that we’ve recently done a survey to tease out a little information about, or a little better understanding about the relationship between mental health and incontinence in general.

Not only sleep related, but just, the way that incontinence can affect the way that you view yourself and your interactions with friends and family and work and the world. And it really can be really debilitating for a lot of people. So it’s certainly not a surprise to hear that.

Now, one of the things that, that you, we were talking about sleep and getting up… one of the other things that we’ve heard a lot is a real concern is about falling. And, especially when people are getting up at night that, there is a greater likelihood of having a fall. And maybe you could talk a little bit about that and what that means for people who are living with symptoms.

Dr. Duncan: So we tend to have language around bladder leaks that is about the bladder leaks getting worse, but it’s not always that simple. Sometimes what’s happening is the body and its ability to move quickly is also getting worse.

So when a person has to get up and move quickly to go to the bathroom, because again, a lot of times the leakage that we’re talking about, the underlying issue can be overactive bladder, and the person’s trying to get there, they can’t. And so the falls are often correlated with overactive-bladder-related incontinence.

We have good literature to support this, and those people are not able to hustle and get to the bathroom on time. For example, I take care of a lot of people in their twenties who have overactive bladder. They tend to be dry, they tend to be able to hustle and get to the bathroom quickly, but over their lifetime with aging and changes and all of the things that happen throughout life, we get then maybe some weight gain, some arthritis. Now we’re using a cane and depending on where that person is in their bladder health journey they just can’t get there fast enough. So it isn’t always just that the leaks have gotten worse, it’s that it’s compounded by maybe some other changes that are happening, too.

And so as the person wakes up in the middle of the night to go, they’re disoriented, the light is out, the “Oh my God I better go to the restroom.” And so that person is jumping up and going, and they’re, again, disoriented, not that mobile to begin with in a lot of cases, and those are the people who are ending up falling and really hurting themselves.

And we try to have people in that case have either a bedroom near a bathroom, or even have a bedside commode if it’s gotten that bad, to try and prevent that from happening. Of course I’m always a fan of trying to treat the incontinence. I’m not just saying, “Oh, go and get a bedside commode.”

I don’t care if someone’s 90 years old who comes in to see me or any provider. They deserve a workup. There’s no magical age at which this becomes acceptable. If a person’s willing to do a bladder diary and do a troubleshooting session with me, then I think sometimes we can find things no matter the age, no matter the circumstances.

But that’s why it’s so bad is that usually you have these other mobility issues coming into play as the incontinence is rearing its head more and more. 

Bruce Kassover: Okay. So incontinence is more than just leaks and it can have ramifications that go beyond just your immediate symptoms. So how can addressing incontinence early change your long-term health outlook? What can, seeking help now do to improve things well down the road? 

Dr. Duncan: I’m going to zoom out one more time and say that there is no symptom too small. Before incontinence occurs, in the majority of cases, there’s other symptoms, little bit of frequency, little bit of urgency, little dribble that isn’t explained. A sense that maybe the bladder isn’t emptied out.

And then with time, things can progress. And the first thing I want to say is that you don’t need to be severe to ask to be seen and advocate for yourself to get care . 

Why do I think treating that early can help? I don’t have a Level One medical evidence study to quote to you all that says, “Hey, if we treat or intervene early it helps in the long run.”

I just have my own experience to, I wish we had that, that we would have that study one day, but we don’t right now. So based on my experience and what I know to be true, I do think it’s easier to treat people at the earlier stages, educate them and get on top of their bladder health and their pelvic floor muscle health and any sort of structural issues they may have earlier than later.

And I just know the people that I’ve seen and treated earlier tend to do better. That does not mean that it’s ever too late, though, it is never too late. I’ve also seen very severe people where we had things we could offer them. And I will say in urology we have, and also in urogynecology and pelvic health in general, this quality of life metric, which I personally think is very problematic – I’ve written some stuff about it recently – and the reason I think it’s problematic is quality of life says, “Hey Bruce, do you find that your bladder is affecting your ability to go to church, hang out with your friends, drive a car and live your life?” And you’re like, “No it’s not.” Let’s say that you’re getting up twice a night, but you’re still able to function, come to work in the morning and do what you need to do, live your life.

You are still experiencing negative health effects from that disruption in your sleep, and that matters. It’s also possible your bladder’s giving you a signal that you have sleep apnea. That’s something that’s very treatable, and if not treated can be a problem. And so we’re asking people to be very bad off if we just sit and think about it for a second, quality of life is asking us to be at the point of altering our life and our basic daily living activities before we step in and do something. And I think because that language is common throughout these specialties, we are trained to look at patients that way. And so the end effect of that is that people aren’t getting treated soon enough.

So I don’t have a study to quote you, but I can tell you that just being a clinician, the earlier the better. And there should be no symptom too small, and no one should ever have to apologize because they have just one leak a day. They shouldn’t need to be in Depends for care, if that makes sense. 

Bruce Kassover: It makes perfect sense. And I certainly hope that if somebody has one leak a day, that they would realize that’s one leak too many and that they do go out and seek help that can really make a difference for them, not just now but well down the road. So I appreciate that and thank you.

And that reminds me that this is Life Without Leaks, and one of the things we always like to do before we, before we’re done is leave our listeners, our guests with one little hint, tip strategy, bit of advice to live a life without leaks. So maybe you have one you could share with us today. 

Dr. Duncan: I would love to. I’ve talked today about a lot of different things that can contribute to the architecture of what’s going on in your bladder and pelvic health. The tapestry, if you will.

And this is going to sound like a silly thing to say, but bear with me. Don’t get distracted by the leakage. Your doctors may get distracted by the leakage, but try not to get distracted by the leakage, because underneath that lies great opportunity, like treating the low vaginal estrogen, treating vaginitis because those things are very simple to treat and take care of, and they may be making the leaks worse.

And so I would ask to tune in to those things and think of some of the simple tips I’ve given, like what medications you’re taking at night that might be causing your bladder to leak, like diuretics. So the leakage itself very distracting. Look at that underlying architecture of the problem and you’ll find yourself with less leaks.

Bruce Kassover: That’s a fantastic tip and I really appreciate hearing it. So thank you so much and thank you for joining us today. 

Dr. Duncan: Thank you so much for having me. I love to talk about bladder health and thank you for giving me the opportunity. 

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.