Redefining "Normal" for Female Incontinence
Mia A. Swartz, MD, MS, FPMRS, discusses female pelvic health as an approachable topic to help normalize the conversation about female incontinence and educating women that while it is a common problem, it is not normal to experience female incontinence and women should feel empowered to talk to their doctor about their symptoms. She shares how you know when it’s time to seek help and the treatment options available at EvergreenHealth.
Melanie Cole, MS (Host): Nearly 30% of all women will develop a pelvic floor disorder in some point of their lifetime, but many don’t seek help. They may be too embarrassed to talk about their symptoms or they think it’s a normal part of aging. You're listening to Checkup Chat with EvergreenHealth and we are talking with Dr. Mia Swartz. She’s a urogynecologist with Evergreen Health. Dr. Swartz tell us first what’s a urogynecologist?
Mia A. Swartz, MD, MS, FPMRS (Guest): Well hello and thank you for having me. I would love to tell you all about urogynecology. Urogynecology is a field that fuses urology, which is surgery and specializing in the urinary tract, with gynecology, which is more women’s reproductive health. This specialty was formally recognized by American Board of Medical Specialties in 2013. So, it is a relatively newly recognized specialty.
Host: So, something that I said in my intro is that people think it’s a normal part of aging to go through some of the pelvic health issues we’re going to discuss today. Let’s start with incontinence. Is that a normal part of aging?
Dr. Swartz: That’s a great question. I think sometimes people confuse normal with common. So, I would say that as people age, the occurrence or incidence of incontinence rises, but that doesn’t make it normal. Sometimes I use the comparison of high blood pressure increases in incidence as we age. Is it normal? No. Is it common? Yes.
Host: How do women describe these conditions to you? Do you find that they're embarrassed to discuss whether it’s incontinence or pelvic pain? Are they embarrassed?
Dr. Swartz: There’s a lot of embarrassment and shame around these symptoms. In spite of them being very, very common, they’re very embarrassing for women to talk about. They also involve areas, such as the genitals, that in general we also have a little bit of shame and embarrassment around culturally speaking. So, once you get a problem with one of the organs “down there”— so your bladder, your rectum, your vagina—it can be a difficult topic to tackle. It often takes a lot a bravery for women to even bring it up to their doctor, let alone present to a specialist like me to try to take on the issue and treat it.
Host: Well as a woman who’s had babies, I'm certainly not embarrassed to discuss it with my healthcare provider because it happens. Then you want to wonder what to do about it. So, tell us, if we know, what some of the causes of incontinence are.
Dr. Swartz: Well I like that you brought up the pregnancy issue because I think that socially speaking, that is the first time that the pelvic floor muscles and the pelvic organs the medical care system, right? It’s when a woman becomes pregnant. But that doesn’t mean that’s the first time she may or may not have an issue. She might have had an issue with her bladder beginning from the time that she was a child or a teenager. So, I want to acknowledge that out the gate. Clearly there’s a timepoint, typically for most women who go on to have children where, again, their pelvic floor and pelvic kind of comes forward at the time of pregnancy. In fact, there can be a rise in symptoms like incontinence and other various pelvic symptoms after childbirth. So that becomes kind of a more socially acceptable time to talk about it for some women.
In some countries, actually, it’s routine for every woman who has a child to go through six weeks of physiotherapy. Completely routine. In our country, it’s a little bit more a “call us if you have a problem”. So, we have quite an epidemic of pelvic health disorders as a result. That’s something that I love to tackle with any aged woman and any woman who’s postpartum.
Host: When would you advise women to call you? And even men, for that matter, can experience incontinence and problems with their pelvic floor. When do you say, “if you’ve had enough, that’s when you call me”?
Dr. Swartz: I literally say anytime. There is no amount of leakage that is too small. You don’t need to wait until you're in Depends or even liners. If you're leaking at all and it’s concerning to you, you should come in. Personally, I think every woman should go through some sort of an evaluation if they have any kind of symptoms.
Secondly, you mentioned men in passing. I know we’re talking a little bit more about women’s health, but you're absolutely right. We talk more about women’s pelvic muscle health and urinary, bowel, and sexual symptoms, but men also have a pelvic floor. I think that’s important to mention even if in passing today.
Host: Let’s talk about some of the treatments. If someone does come to you and they’ve garnered up the strength to come and discuss this problem with you, what are some of the first things that you would try? We’ve all heard about “Kagel” exercises, or Kegel if you say it that way, tell us a little bit about what those are or what we can try first before other discussions come up.
Dr. Swartz: I love that question. So, with all of the mesh adds on television, we’ve done a huge disservice to women. What I’ve seen in the last five to ten years is that there’s a lot of fear, on top of the shame and embarrassment about many of these issues to begin with. There’s also a fear now that if you come in to see a specialist like me that you're going to get chased down for a surgery against your will, and that the only option a vaginal mesh of some sort. So, I'm here to tell you that there are many, many options that don’t involve surgery. Some of those are very, very holistic. Some of the most major things that we do are lifestyle modification, which can involve weight loss, fluid modification. Some women actually drink too much fluid. Some women drink too little fluid. Both of things can contribute to bladder problems. So that’s the starting point.
The second point is pelvic floor physiotherapy. That rehab program you get routinely if you were a woman living in the UK for instance. So, bringing that in to make sure that the muscles are working properly. Thank you for mentioning Kegels because that’s what every woman has heard is everybody needs to do Kegels. It’s important to say that there is a large percentage of women that actually can be harmed by doing Kegels. So being supervised by an appropriate practitioner before starting a Kegel program is advisable. Once you're tried all of these various lifestyle modifications, physiotherapy, then we can begin talking about medications if appropriate and procedures, such as in-office treatment options or even surgical options.
Host: I’m glad you mentioned pelvic floor physiotherapy because that’s really a burgeoning field today. So, if we've tried all of those things and we've seen the commercials for some of the medications, what would be available to help with this?
Dr. Swartz: When we’re talking about incontinence and treatments, you’ve hit on another really important point. All incontinence is not the same. When we, as women, sit around and maybe over a glass of wine chat with our friends, there’s this oh I have that too. But really when it comes down to it, there are different types of incontinence and the treatments differ. So, there’s the type of incontinence or leakage of small drops that occurs when a woman coughs, jumps, runs, or strains, and so that’s called stress urinary incontinence. The mechanism for that and the treatments for that are different from the other type of leakage, which is getting an urgency to go to the bathroom that is difficult to differ such that you leak or drops of urine escape before you hit the bathroom. Even large volumes can gush out without warning. There’s lots of shades of incontinence types in between, but those are the two main ones.
So, if you're talking about medications and ads on television, those are targeted towards the urgency type of leakage, which can also be referred to as overactive bladder. When those medications don’t work, there are other options such as bladder Botox injection and nerve stimulation procedures like acupuncture style therapies, and even little implants that can regulate the nerves to the bladder. You notice that in none of those options did I mention a mesh sling. In fact, that’s a treatment for the stress urinary incontinence. Even that has more than just a mesh sling available to treat it. There’s agents called bulking agents, which are silicone based, that are little outpatient day procedures that can be performed as well. So again, lots of options, but they do very on the type of leakage or incontinence. If that makes sense.
Host: It does and that’s so interesting the way that you’ve just explained it all Dr. Swartz. When does the discussion become around surgical interventions?
Dr. Swartz: You know it really comes down to the person’s bother. One thing I explain to people is that this is not a field like cancer, right. It’s not an “Oh, this is a bad mole. So, we’re going to just remove it.” You understand what I'm saying? It’s not a binary type of decision tree. It very much is how much the woman is affected by her symptoms. I have women that are housebound because they leak two or three times a week. I have other women that happily wear pads and they don’t want any care for their problem, even after being educated about their options. So, it’s a very private and intimate decision and a very personal one if that makes sense.
Host: It does. What I’d like to ask you is that since so many women with incontinence don’t report it to their physicians, do you think, in your opinion, physicians should take an active approach and ask specific questions such as onset symptoms? Should this be a part of a health and wellness exam?
Dr. Swartz: In a perfect world, yes. I would love for that to be the case because this is not a rare condition. Realistically as people age, and again this can occur at any age, but realistically speaking the older a person gets, the more likely it is they're going to have leakage. Then also the more likely it is that they're going to have high blood pressure, diabetes, and other things that overwhelm the primary care doctor in a medical environment that has increasing demands on them with less time. So that’s where we come in. I would love to see a screening happen for every person, but I don’t think that would realistically happen.
Where I actually would love to see it, and I think it could be realistically implemented and something we’re trying to do at Evergreen is really screening every pregnant woman. That’s a touch point for maybe not every woman, but it is a touch point where we can really make a healthcare intervention that is meaningful for women in the long term.
Host: As we wrap up, what would you like people know about this subject, this topic? And what they can do at home as far as lifestyle, exercises? Should they keep avoiding diary? What would you like us to do before we would come in to see you for incontinence?
Dr. Swartz: I think the biggest thing is that if you have any trouble emptying your bladder, if you have any leakage, any urinary concerns, don’t consider them to be unimportant. Come in and see somebody. The same goes for pelvic pain, sexual pain, bowel dysfunction, any of that. Come in and see somebody. As far what you can do at home, that’s a little bit more difficult because that is tailored often to the individual’s symptoms. However, what I want to say is that a good intake of fluid is about 65 ounces a day. You don’t want to drink too little and you don’t want drink too much. They can both be problematic. Keeping your weight down and in sort of a healthy age range is also associated with improved continence. Just staying, in general, fit and healthy. Those things would be the top things. Of course, dietary irritants, like we love our coffee in Seattle, right? Those things are not great for bladder irritability and certain types of bladder leakage. So, staying away from things like that. Minimizing alcohol and carbonated beverages are also really helpful basic lifestyle changes.
Host: Thank you so much Dr. Swartz for being with us today, and for discussing so clearly an issue that women and men can go through and that they may be too embarrassed to discuss. Thank you for letting us know it’s okay to discuss it with our healthcare providers and to come in if it’s bothering you at all. Thank you again, Dr. Mia Swartz, Urogynecologist at EvergreenHealth. You're listening to Checkup Chat with Evergreen Health. For more information on the latest advances in medicine, please visit evergreenhealth.com. That’s evergreenhealth.com. This is Melanie Cole. Thanks so much for listening.