Ask Us Anything About… Incontinence

Scott Gilbert – From Penn State Health, this is, Ask Us Anything About Incontinence. I’m Scott Gilbert. Urinary incontinence is a common but nonetheless frustrating and embarrassing problem. The good news is that for most people, lifestyle changes or medical treatment can help to alleviate the problem. And we’re going to learn more about it, including those innovative treatments from Dr. Joe Littlejohn. He’s a Urologist at Penn State Health, Milton S. Hershey Medical Center. Dr. Littlejohn, good to have you with us. Thanks for being here this afternoon.

Dr. Joe Littlejohn – Hello, Scott. Nice to meet you. Nice to see you today.

Scott Gilbert – Yeah, same. So I guess we should probably start by emphasizing that urinary incontinence in itself isn’t a disease. It’s a symptom, correct?

Dr. Joe Littlejohn – Yes, it can be a symptom of a problem, an underlying problem, but it’s more of a medical condition, I would say. Yeah, it’s a medical condition that it certainly deserves attention. And it’s a very important medical condition. But yeah, you’re right, I wouldn’t call it a disease.

Scott Gilbert – And how common is it? Especially demographically to men, women, age-wise, that kind of thing?

Dr. Joe Littlejohn – So there’s a study out of Boston, a Community Health Study, this was probably 2008. But still that study showed that it’s probably about 10.4% of women have some form of incontinence weekly. And the more common types that they were referring to in that particular study where the stress urinary incontinence and urgency incontinence. Or a combination of the two referred to as mixed urinary incontinence. So 10.9 — 10.4% of women between the ages of 30 and 79 would have weekly incontinence episodes.

Scott Gilbert – You’ve got those numbers right at the tip of your tongue there. Let’s talk about a couple of those different types that you brought up, starting with stress incontinence. So what is it, and what causes it?

Dr. Joe Littlejohn – So stress urinary incontinence is leakage associated with abdominal pressure, so increased abdominal pressure. That could result from a cough or sneeze, a laugh, lifting, anything that causes increased abdominal pressure resulting in involuntary leakage of urine. That would be stress urinary incontinence. So what causes it? Well, it’s weakening of the pelvic floor. And that weakening can be sustained from childbirth. And it might not happen immediately after childbirth. But certainly, there is some wear and tear on the pelvic floor, musculature, and ligaments of that area, the connective tissue of that area associated with childbirth, and with that, in association with aging, can result in this involuntary leakage.

Scott Gilbert – And so you mentioned that those are some of the causes then that it’s, you mentioned childbirth. When we hear about women saying boy, ever since I had kids, it’s hard for me to control certain things, that’s stress incontinence then?

Dr. Joe Littlejohn – Yeah, that’s typically stress incontinence. You can have, you know, urgency incontinence, too, and it could be something that happens in younger women for various reasons. But the stress incontinence would generally be that associated childbirth, the childbirth process.

Scott Gilbert – So then let’s go to urge incontinence. What are the causes of that, and you know, how does that differ from stress incontinence?

Dr. Joe Littlejohn – So urge incontinence would be the involuntary leakage of urine associated with a bladder contraction that was involuntary. So the bladder usually kind of fills compliantly. It will gradually fill up, and when it’s full, it does not contract until you’re in a socially acceptable situation where it’s okay to empty your bladder. Your brain is part of that process. There’s a Pontine micturition center, a center in the brain that helps coordinate all this. But the bottom line is, your bladder just will fill compliantly. And a message from the bladder will be sent to the brain that hey, it’s full, let’s go head to a restroom. Then the brain will decide to relax the voluntary muscle below the bladder or the external sphincter, and that will send a reflex to the bladder. The bladder is an involuntary muscle. So we don’t voluntarily decide to contract our bladder. We voluntarily decide to relax our external sphincter, and the bladder will spontaneously contract. Now that’s the normal process. Well, the abnormal process is when this bladder starts to contract before we’re ready. And on the way to the restroom, your bladder may contract. You get the urge to go, the bladder starts contracting, and you’re fighting to keep that urine in by contracting the external sphincter to try to hold that in, and sometimes we’re not able to do so. So that would be the urge urinary incontinence.

Scott Gilbert – And you mentioned that attempt to hold it in. So there’s some kind of muscle involved then on the inside. Is that essentially what that sphincter is?

Dr. Joe Littlejohn – Yeah. So the same sphincter we use to, you know, hold in urine is the same that we use to hold in stool. It’s a levator ani muscle, the pelvic floor musculature. It’s made up of various muscles, but those muscles work in concert to hold our stool and our urine in. So when you don’t want to pass gas and public per se, and we tighten that muscle group, that’s the same muscle group that holds the urine in as well, and we refer to it as the external sphincter. And that is actually a voluntary muscle. You can voluntarily relax that when you urinate. And that is what’s under our voluntary control. But contracting the bladder is more of a reflex of an involuntary muscle.

Scott Gilbert – And again, as a urologist, you specialize in urinary incontinence. So if someone had incontinence related to feces, that would be handled by a gastrointestinal physician?

Dr. Joe Littlejohn – Well, yeah, I mean, well, there’s little crossover, interestingly enough. The colorectal surgeons would be over the surgical aspect of fecal incontinence. However, the same treatment for urinary incontinence or urge urinary incontinence that’s refractory to medical therapy or a third-line therapy is called sacral neuromodulation. And that same procedure done the same way is utilized for fecal incontinence. In fact, yesterday, I was in the OR with a colorectal surgeon. And, you know, we do a lot more because we see a lot more urge incontinence than refractory fecal incontinence than even the colorectal surgeons do. So since it’s not as common a case for them, I was asked to come into the OR with a colorectal surgeon to go through a case. So it’s implanted exactly the same way for fecal incontinence. And oftentimes, we’ll have patients with what they call, now this gets a little confusing, not mixed, but we’re talking about dual incontinence. So dual incontinence is when you have urge urinary incontinence and fecal incontinence. So in a patient with dual incontinence, they may present to the urologist, and you know, we would take over the care in that sense, thereby treating their fecal incontinence at the same time as treating their urge incontinence.

Scott Gilbert – You’re watching Ask Us Anything About incontinence from Penn State Health. I’m Scott Gilbert. That’s Dr. Joe Littlejohn. He’s a urologist at the Milton S. Hershey Medical Center. We welcome your questions and your comments here. Feel free to put them in the comment field below this Facebook post. Also, we realize it’s a sensitive matter. So if you’d rather send your questions privately through Facebook Messenger, you can do that. Send them directly to our page offline, and we have our social media specialists monitoring that inbox. And we will pass your question along anonymously over the course of this program here. There is a bit of a stigma here, Dr. Littlejohn. Right? I mean, how often do you see people who have really put off coming to you until they feel that the problem was just, you know, so big that they couldn’t deal with it anymore? And then they perhaps could have come to us sooner, but again, there’s that hesitation at play.

Dr. Joe Littlejohn – So yeah, I mean, that’s absolutely true. At some point, however, the embarrassment can build up on their side where it’s not any longer something that they can hide or cover-up in a sense. So I think there’s a tipping point where, you know, the coping mechanisms and the pad use and whatnot, aren’t enough to, you know, keep this issue discreet. So, therefore, they seek attention, and I think, the earlier, the better. A lot of times, patients will undergo therapy. I’ve had patients with stress incontinence say why didn’t I do this 10 years ago. I’ve had patients with urge incontinence get treatment and say, wow, now I can travel again. You know, it is something that once they actually seek care, we usually are able to make them better. And it’s not always surgical. So sometimes we achieve our, you know, our goals without going to surgery. We do have first-line therapy for each of those treatments. First-line and second-line therapy and even third-line therapies for stress and urge. And the earlier therapies are more conservative.

Scott Gilbert – And we’ll definitely get to those treatments very shortly. I want to get to a little bit more also about some of those medical conditions that can cause urinary incontinence because there’s several of them. Right?

Dr. Joe Littlejohn – Well, if you’re talking about urinary incontinence in its broadest definition, then absolutely there’s a ton of things that it can cause. But if we kind of focus in on stress urinary incontinence, you know, and we look at the female population, we kind of touched on the two things, childbirth, obesity would be another thing, you know, aging, those would be the predisposing factors. There are certain medical conditions where you can have weakening of your connective tissue, and you could be predisposed. Weak collagen production or collagen synthesis abnormalities can result in predisposition to things like this as well. And that’s on the stress urinary incontinence side. In terms of urgency incontinence, you know, there are also a host of medical conditions that can predispose a person to that. You know, there are things that can occur within the bladder that could be a sign of pathology, such as infection, cystitis, or inflammation of the bladder. You could have, you know, stones within the bladder, or even, you know, tumors and growths within the bladder that can cause the bladder to become, you know, more contractile, irritative and result in incontinence. Now, there are other things that are outside of the bladder as well, like spinal cord injuries. People don’t really think of spinal pathology as being a risk factor. But believe it or not, herniated discs, nerve problems interfere with that interplay between the brain and the bladder, and that communication that’s always ongoing. And they can have urge incontinence on the basis of spinal pathology.

Scott Gilbert – It’s Ask Us Anything About Incontinence, from Penn State Health. We welcome your questions for Dr. Joe Littlejohn. Feel free to put them in the comment field below this Facebook post. And of course, as we noted before, you can feel free to ask your questions privately and anonymously if you wish, through Facebook Messenger. Just send those to our page, and we’ll make sure that we pass those questions along. Again, it will be live, but it will be anonymously as well. So your name is not attached to it if you choose to go that way. So yeah, we talked a little bit about the negative effects of incontinence and the lifestyle. And what strikes me about that is the inverse. Right? Because you mentioned how you feel like you’re kind of giving people their life back when they undergo this treatment. I imagine there’s probably a gradual effect on their lifestyle that they may not even notice or make excuses. Right? And then say, oh, well, yeah, I don’t really want to do that anymore. But then they get their life back when they seek treatment.

Dr. Joe Littlejohn – Yeah, you’re right. In some individuals, it’s a gradual thing, and it builds up, and eventually, they seek treatment. The response to therapy is typically really dramatic and quick. So both for urge and stress incontinence, as you reach the stage of requiring an intervention, the intervention doesn’t take a while to, you know, realize its effect. It’s pretty dramatic right away. So although it took a while for them to develop the problem, the fix is pretty quick. And that’s what makes it so dramatic to them. And they can say, wow, this is what it was like to not have this problem. And that’s pretty impressive.

Scott Gilbert – So I want to know, like, how do you define a diuretic? I know, I think this is one of them. Right? And do they cause actual incontinence, or is the urgency associated with consuming diuretics and that type of thing more of — it’s not really officially clinical incontinence.

Dr. Joe Littlejohn – So, you know, diuretics don’t really cause incontinence at all. Basically, what they do is allow fluid that’s retained in the tissues. So the tissues in your bloodstream to be, you know, excreted in the urine. So what we’re doing is we are, through the kidneys, we’re increasing our urine volume. So that would be akin to drinking a lot of fluid. So a person with urge incontinence or the predisposition to urgency and urge incontinence who drinks a lot of fluid, their kidneys are going to be making a lot more urine. And a person who takes a diuretic, their kidneys are going to be producing a lot more urine. And the fact that they’re producing a lot more urine brings out the symptomatology. So if you had urge incontinence, typically — or urgency, your bladder may feel full before it’s actually full. So a certain volume that’s lower than what you would consider normal might stimulate the urge to urinate. So your container is smaller, so you go to the bathroom more frequently. Now, if you take a diuretic and you’re pouring more volume into the smaller container, you’re going to be going to the bathroom more frequently and likely having more accidents. But the diuretic in and of itself does not cause incontinence.

Scott Gilbert – Okay. And yeah, let’s talk a little bit about some of the treatments. Because you mentioned surgery before and there are some devices, and we’ll get to those. But not everybody reaches that stage. Right? Because in some cases, I understand behavioral techniques or medicine is enough to get people back to their lifestyle.

Dr. Joe Littlejohn – Absolutely. Now, let’s take stress urinary incontinence. So, yeah, I have a person with stress urinary incontinence, and they come in. It’s known that people will get dramatically better by simply doing pelvic floor exercises. The problem is that we’re not the best at describing pelvic floor exercises to patients. So probably about 25% of patients will get the message from the doctor explaining what a pelvic floor exercise is, or the Kegel exercise. It’s tightening the pelvic floor musculature and contracting it and holding it one or two seconds and relaxing it. And usually, a person should do sets of 20 three times per day. And that will dramatically improve 80% of stress incontinence. Just doing that exercise for one complete month, you’ll have, you know, 80% of stress incontinence will be significantly better. So, but again, describing it or the doctor telling a patient do is not very effective. So that should be augmented with maybe literature, showing a patient how to do that. And sometimes sending the patient to a pelvic floor physical therapist that can really make sure the person is actively contracting the muscles that we want them to contract.

Scott Gilbert – Okay. So then let’s talk a little about some of the therapies that are out there because there are some devices and therapies. I know slings and bulking agents are two categories of those. Can you explain each of those briefly?

Dr. Joe Littlejohn – So, the bulking agent would be an injection of a material underneath the mucosa of the urethra. So you have a layer aligning, kind of like a skin, or the lining inside of your mouth, that lines the urethra. And through a telescope, we’re able to place a needle underneath that lining and inject a material. So there’s various materials that have been used. The bulking agents then will cause what we call a coaptation, or a sort of a closure of the urethra. Not enough to close it to prevent or obstruct urine flow, but enough to close it and coapt it enough to prevent leakage or involuntary leakage with stress. So, therefore, the bulking agent serves as a mechanical obstruction to involuntary loss of urine. The downside to bulking agents traditionally was the fact that they weren’t very durable. There’s a newer agent that’s out now that has shown some really good durability. And I’m excited about, you know, that prospect, having a minimally invasive procedure that is also durable.

Scott Gilbert – I was going to say, what are some of the cutting edge treatments, things that may even be in clinical trials right now? I mean, this is a field I’m sure that, like many others, is still rapidly developing. Correct?

Dr. Joe Littlejohn – Oh, absolutely, yes. Well, I would think the regenerative technologies such as stem cell would be the ones that would be probably the most exciting kind of therapies where you’re injecting — potentially injecting or surgically implanting a material that has the likelihood of regenerating the tissue planes that were previously there, or the types of tissue that were in the area to re-support the pelvic floor. Those would be the things that would be on the horizon that would be, you know, we’d be looking out for. The things that are actually available and new in this area, I would say the newest treatment for stress urinary incontinence would be what we just talked about, which is the bulking agent with sort of a hydrogel. And so mainly a water gel, a water-based gel that serves as a bulking agent, is found to be very, very durable in the bulking agent. And yeah, that’s the one that I think would be in that category. There’s also some fairly new and exciting things that are going on in the urge incontinence world as well.

Scott Gilbert – You’re watching Ask Us Anything About Incontinence. We welcome your questions for Dr. Joe Littlejohn. He’s a urologist at the Milton S. Hershey Medical Center. And now is a great time to ask your questions either in the comment field, or if you’d like to send us a question privately through Facebook Messenger, you can do that. We do have a question from a viewer about pelvic organ prolapse, asking what some treatment options are for that? Can you start by explaining what that is? And then talk about how that’s commonly treated?

Dr. Joe Littlejohn – Yes, so the vagina has an anterior border. And right above the top of the vagina is the bladder. The bladder kind of sits right there. On the lower aspect or the posterior floor of the vagina, the rectum is there. Above on the top is the uterus unless a patient has had a hysterectomy, in which now they have a vaginal cuff. And then the intestines. And the small intestines sort of sit on that aspect, and that’s called the apex of the vagina. So any wall, where they can have an anterior prolapse, we call the cystocele when the bladder is kind of prolapsing down into the vaginal vault or below, outside of the vagina. The apex can fall down and do the same thing with your sort of small intestines, you know, pushing their way through and into the vagina or out. And the rectum can also bulge into the vagina from below and push its way out. These problems can result in various types of issues. Difficulty urinating, difficulty defecating, and pain and pressure. And that’s pretty much what pelvic organ prolapse is.

Scott Gilbert – Sure, so how is it treated typically?

Dr. Joe Littlejohn – So, you know, we have conservative, going up to more aggressive or surgical therapy. So we’ll start, well, a pessary. That’s just a mechanical, sort of synthetic doughnut type of a device, more like a diaphragm that’s soft and pliable. And you can place that in the vagina in order to keep the pelvic organ from prolapsing. And that would be a non-surgical approach, usually done by the gynecologist. They will fit a patient and place a pessary, and then it would have to be periodically removed and cleaned. So that is one way of dealing with the problem. But if you’re talking surgical repair, there are what we call anterior and posterior Colporrhaphy, where we repair those things through the vagina. You’ve probably heard a lot of issues about the mesh that has been recalled. Those mesh repairs, large mesh repairs that were transvaginal using a polypropylene mesh through a large incision in the vagina, were fraught with a lot of complications. Probably from the mesh not being placed in the right place where they then eroded into the bladder, if they were placed too deeply, or if they placed too superficially, eroding into the vagina. So those were the older things. The FDA actually pulled those repairs. Those mesh repairs are no longer available. But fixing them through the vagina is one way. And another way of fixing it is the way that I prefer, which is a transabdominal approach where we use the minimally invasive da Vinci robot to place. Again, we use polypropylene mesh. But the way it’s utilized is not through a large transvaginal incision. It’s more of a supportive way to use it and kind of replicating previous tissues and an orientation that’s more normal. And doesn’t result in the same degree of erosion as a durable, long-lasting approach to fix the cystocele, rectocele and the apical descent all in one procedure.

Scott Gilbert – Interesting stuff. Well, Dr. Joe Littlejohn, thank you for all the great information today. And I’m sure if people would like to seek some more information about their particular situation, they can contact the Urology Clinic. We’ll make sure that we put some of that contact information in the comment field below this Facebook post after this broadcast. So Dr. Joe Littlejohn, thank you very much for your time today, and thank you for watching Ask Us Anything About incontinence from Penn State Health.

Dr. Joe Littlejohn – Thank you.