What Causes Urinary Incontinence and Other Pelvic Floor Disorders? (podcast)

Pelvic floor actually is a group of muscles. You don’t see them, but they are there supporting the weight of your entire trunk, all the time.

Yes. That is one reason. Sometimes those muscles get injured during childbirth. Obesity puts a lot of strain on those muscles. Smoking causes those muscles not to work in the most optimal fashion.

If you lead a sedentary lifestyle, and don’t strengthen your muscles overall, then those muscles suffer and that can lead to some bowel and bladder issues.

[Also] childbirth is a wonderful experience, but it is also a very traumatic experience for the nerves. The nerves get compressed.

There are two main types of urinary leakage. One is called stress urinary incontinence. It has nothing to do with mental stress, though it can cause mental stress. It’s got more to do with the stress of some bodily activities like jumping or exercising on your bladder. There is a ring of muscle that sits right at the neck of the bladder. The job of those muscles is to squeeze tightly every time you perform those activities. Now when those muscles become weak, urine escapes and this is called stress leakage, which is associated with coughing, sneezing, laughing, lifting and those type of activities.

The other kind of leakage is called overactive bladder and just like the name suggests, your bladder is working overtime. So, it’s hypervigilant, hyperactive. You’re using the restroom very frequently. When the urge hits you, it hits you very strongly and often time you’re running to the restroom and even before you get there, you’re having accidents. That is an overactive bladder.

Family history is huge. Ethnicity too. We do see it more among women who are from Norwegian lines. We see it among more Hispanic women. It is less common among African-American women.

Other risk factors are obesity. That’s a big risk factor. The number of vaginal children that you’ve had also contributes to the injury to the pelvic floor, leading to higher incidence of bladder leakage.

Menopause definitely contributes to it. I think it has more to do with just aging and menopause. Both those factors are intermingled. Studies suggest there are hormonal receptors in the bladder as well as in the pelvic musculature. While we can’t really pinpoint menopause as the obvious cause of all bladder leakage, we definitely think there is a risk factor.

I wouldn’t say hysterectomy is a risk factor for bladder leakage. Hysterectomy slightly increases your risk factor for prolapse, which is a different condition.

Uterine prolapse would not be the best way to describe things. I would say pelvic organ prolapse or vaginal prolapse. What happens is that the vagina walls have an inherent system of scaffolding called the connective tissue. As we age, that connective tissue does not work optimally. Women with certain genetic predispositions are more likely to have degradation of their connective tissue. When we lose that connective tissue, the vagina walls begin to descend and come out of the vaginal opening, and that is prolapse.

Now, attached or surrounding the vagina is the uterus, the bladder, the rectum, and we find that as the vagina walls are collapsing, those organs get displaced as well. So, prolapse is a condition that affects the uterus, bladder and rectum, and is essentially a weakness of the vaginal walls.

There are a lot of minimally invasive surgeries, such as robotic and laparoscopic surgeries. But, one shouldn’t forget to mention vaginal surgery, which is the most minimally invasive surgery that we know. The great thing is that a lot of conditions of the vagina can be fixed through a vaginal approach that requires no external cuts. It’s a natural opening and we can use that to repair the vagina walls.

Laparoscopic and robotic surgeries are minimally invasive surgeries, just like vaginal surgeries. We do them through small incisions. The additional benefit of a robot-assisted surgery is that it actually gives us more wristed motion, which means that we have a better ability to do more detailed dissection. So it takes a step above traditional laparoscopic surgery, which is essential to repairing the vagina.

With most of these surgeries, you leave the same day. Sometimes it’s just a 23-hour stay, just an overnight stay. But a lot of women leave the same day.

And as far as restrictions are concerned, they are not very harsh. In general, we’ll tell you to give your pelvic area some rest, not to lift heavy objects and make sure that your husbands are doing all the heavy work.

For bladder leakage, there are multiple treatment options. And, treatment options are really tailored according to how bad the condition is and what kind of leakage that you have.

People who present with mild symptoms, symptoms that are showing up maybe a few times a week — maybe it’s moderately affecting your quality of life, but it just doesn’t bring your life to a stand still — probably pelvic floor physical therapy would be a great option.

A therapist would help retrain your pelvic muscles, retrain your bladder. So, that’s one option.

Another option is a pessary. A pessary is a little plastic removable device. Think of it like a tampon or one of the Diva Cups or menstrual cups that women often use. It goes inside the vagina. If you have one in, you’re not aware of it, and it gently compresses the neck of the bladder and prevents leakage of urine. Just like eyeglasses, contact lenses, it requires some maintenance. And then there is the final option of surgery which is definitely more of a long-term fix.

For stress leakage, one of the most commonly performed surgeries worldwide is the mid-urethral sling surgery, which has revolutionized our bladder incontinence surgeries.

As for an overactive bladder condition, it comes down to physical therapy, bladder retraining, being very mindful about what you drink and how much you drink.

There are acupuncture treatments that are available, also known as posterior tibial nerve stimulation.

For people who are not interested in those modalities, there are medications.

When people fail a lot of the first and second line treatments, we talk about surgeries, like injecting Botox in the bladder, or putting a nerve stimulator in your spine, which can be a very effective way of managing these issues as well.

If you’re having painful bladder symptoms, burning, pain, urgency, frequent bladder infections, your threshold to see a doctor should be lower. If you are having symptoms of leakage with coughing, sneezing, you’ve just had a baby, and you feel that it’s not affecting your quality of life that much, you can continue to do some home pelvic floor exercises, also called Kegel exercises, and see how that works for you.

There are different ways to describe Kegel exercises. You’re pulling up your vagina, or you’re squeezing your internal muscles. It’s an inside muscle that you are activating and you’re squeezing it at particular repetitions. You don’t need a gym membership to do it.

Pelvic floor physical therapy is prescribed to men and women, and it's for various pelvic floor conditions. Leakage is just one of them.

When you go to a pelvic floor physical therapist, they’re working on actually two factors. One is for you to be a little bit more mindful of your bladder, understand the urges and understand ways to delay those urges. Use your own mind, body techniques, connections, to put off the urge, which is called biofeedback. The other aspect of treatment is rehabilitating those pelvic muscles.

Traditional biofeedback is manual biofeedback, which means that the physical therapist will do a manual examination and give you feedback on whether you are doing the correct exercises or not.

We also have vaginal probes that can study the pelvic muscles. It makes it a little more objective because it assigns you a number. Sometimes people really respond to looking at the graphs while they’re doing the exercises. And so it’s a different way of giving you feedback, which is more audio-visual based and may work really well for some people.

Electrical stimulation does a few things. One is that it improves the nerve muscle connection, how they talk to each other. It also stimulates or invigorates the muscle so that your strength of exercise becomes better. And it also helps dampen some of those strong urges that you may feel that may be coming from the nerves. So it works through multiple pathways.

Physical therapy can be something that some providers will offer in their office through some computerized biofeedback tools with electrical stimulation. It can also be received through specially trained pelvic floor physical therapists. These are not just ordinary physical therapists. These are women, and men for male patients, who undergo special training, extra courses, to provide you with pelvic floor physical therapy.

We have wonderful centers within Scripps that provide this therapy and have private rooms, beautiful private rooms, where you can receive this treatment because this is an embarrassing area of your life and it’s not something you want to do with a group.You can check with your doctor about that or you can call 1-800-SCRIPPS (727-4777) to find the one that's closest to you.

It stands for posterior tibial nerve stimulation. There’s a nerve that runs right behind our ankle. It’s called the posterior tibial nerve. This nerve takes a region from an area in our pelvis that is very close to the nerves that supply the bladder and the bowels as well. We use traditional Chinese medicine and we put an acupuncture needle, a needle as thin as the shaft of my hair that goes in there. We attach it to an electrical stimulator and we deliver electrical stimulation. You receive it once a week for 12 weeks. It’s approximately 30 to 40 minutes per treatment. During that time, the nurses also go over all your diaries, how well you are doing with some of the lifestyle changes that have been recommended to you. The hope is that by the fourth or fifth treatment you will notice significant improvement in strength of urge, how frequently you are using the restroom. Are you waking up a lot at night to urinate? It does impact all that. And it’s a very non-invasive treatment.

Bladder leakage alone, maybe not. But when bladder leakage occurs with other symptoms, like urgency, not being able to make it to the restroom, having the desire to urinate or having blood show up in your urine in the absence of a bladder infection — we call them irritated bladder symptoms — that can sometimes be a harbinger of bladder cancer.