>> And right now I would just
like to go ahead and introduce
Heidi Brown, and she will take
it from here.
Thank you, Dr. Brown.
>> OK, thank you very much.
So I have to tell you all that
my research-- I do research
around promoting awareness about
bladder and bowel continence in
older adults, and my research is
funded by the National
Institutes of Health through the
Department of Urology at
University of Wisconsin, and I
also with an organization called
the Community Academic Aging
Research Network, or CAARN,
which is a partnership between
UW's Institute for Clinical and
Translation Research and the
Wisconsin Institute for Healthy
Aging.
So those are my disclosures of
who supports me in the work that
I do.
Okay, I'm going to start with a
pop quiz, and you don't have to
answer because I'm not going to
tell you the answers anyway, but
at the end of the talk, you will
all know the answers to these
questions.
The first question is this: as a
person over the age of 65, your
chance of having urinary or
bowel leakage is one in two, one
in three, or one in four?
You don't have to answer.
>> [INAUDIBLE]
>> We'll ask again at the end.
Okay, now, what do you think is
more common: high blood
pressure, depression, diabetes,
or incontinence?
Any guesses?
Incontinence.
Incontinence is more common than
all of those other common
medical problems.
And risks for incontinence
include: age, giving birth,
smoking and chronic lung
disease, obesity, prostate
problems, or all of the above?
>> All of the above
>> All of the above.
And true or false: bladder and
bowel control problems only
occur after the age of 50?
False. Okay.
Well, you guys already know all
this, so thank you very much.
I'm going to cancel my talk now.
[LAUGHTER] No.
You don't know what the answer
is to the first question.
That's where I have you hooked.
Okay, we're going to talk a
little bit today about pelvic
floor disorders, which are
problems with bladder control,
bowel control, and pelvic organ
prolapse, and we're also going
to touch on tips and tricks to
help manage or prevent symptoms.
One in three women will
experience a pelvic floor
disorder in her lifetime.
That's a lot of people.
So, what is the pelvic floor?
One in three women are going to
have a problem with it.
What is the pelvic floor?
I recently had a patient who
came into my office, and after
she'd been seeing me for six
months, she said, you know, Dr.
Brown, the first time I came to
see you, I was so nervous.
I wore sweatpants and sneakers
and I told my husband I don't
know if I'm going to be able to
handle this pelvic floor.
I thought it was some sort of a
gym.
[LAUGHTER]
So let me tell you
what the pelvic floor is.
Everybody has one, men and
women.
We all have a pelvic floor.
And the pelvic floor is actually
this bowl of muscles that goes
from our pubic bone in the front
to our tail bone in the back,
and it's a sling of muscles that
support our internal organs.
And it's not just muscles but
also connective tissue, which is
the stuff that connects muscles
and ligaments.
And so men and women all have a
pelvic floor.
Everybody has a pelvic floor,
and it supports whatever
internal organs we have, the
bladder, the uterus and vagina,
the prostate, the rectum, and
the anus.
So, what are pelvic floor
problems and what might you
experience if you have a pelvic
floor problem?
You could have problems with
bladder or bowel control, which
could manifest as feeling pelvic
pressure or a bulge in the
vagina or urine leakage or
incontinence or maybe not
leakage but just overactive
bladder, which is the I got to
go, I got to go.
Or maybe difficulty emptying the
bladder.
Urinary hesitancy.
You feel like you can't start
your stream and then you can't
empty completely.
Or problems having a bowel
movement, or problems with
leakage of gas or stool.
So there are a bunch of
different things that all fall
under the umbrella of pelvic
floor problems.
And as I showed you on the last
slide, all those organs are
really close together.
So there are some risk factors
for pelvic floor disorders, and
you already got the question
right at the beginning of the
quiz but I want to highlight
them.
One in three women develop a
pelvic floor disorder, and that
risk increases with age so that
by the time we get to age 65
it's one in two women who have a
pelvic floor disorder.
And risk factors include
pregnancy, childbirth,
menopause, but pelvic floor
disorders are not just problems
of older women.
One in four younger women in the
20 to 40 age group has a pelvic
floor disorder.
So this isn't just a problem for
older people.
This is a problem for everybody.
There are also lifestyle factors
that can contribute, like being
overweight or obese, not
exercising regularly, smoking
cigarettes, or health
conditions, like having an
injury or surgery in the pelvis
or development of neurologic
problems, like multiple
sclerosis or a stroke or
Parkinson's disease, diabetes,
and then bowel disorders, like
constipation, loose stools,
irritable bowel syndrome,
inflammatory bowel disease.
So lots of common problems are
associated with pelvic floor
disorders.
So there are three major types
of pelvic floor disorders, and
if I wanted to make this talk
shorter, I could just talk about
one or two, but when I do that,
then everybody says, well, why
didn't you talk about the third?
So I have to talk about all
three, and I'm going to go fast,
okay?
I'm going to start with bladder
control, which is the most
common.
And I want to start by telling
you that if you have problems
with bladder control, you're not
alone.
18 million women in the US have
urinary incontinence.
So what does that really mean?
18 million adult women in the US
have urinary incontinence.
Here's a map of the US.
Every red dot is 25,000 women
with urinary incontinence.
This is a lot of people with
urinary incontinence.
We should be talking about this.
It's not just women either.
40% of men and 60% of women over
the age of 65 have problems with
bladder or bowel control.
And we're going to go into more
detail about that recently.
This chart is hard to read, but
it's taken from a report issued
by the Centers for Disease
Control this summer.
They issued their first ever
report about the prevalence of
incontinence in older adults to
really bring attention to the
fact that this is an
underrecognized problem that we
should be taking care of and we
should be paying attention to.
I want to stop and talk a little
bit about how the bladder works,
and I want to point out a few
things.
Okay, this is a picture.
If you were to turn me to the
side and cut me in half and
remove half of my body and look
inside, this is what you would
see.
The pubic bone is right in the
front.
That's that hard bone that you
can feel if you touch in your
lower abdomen.
And your bladder sits right
behind your pubic bone, and
that's why when you get a full
bladder, if somebody presses on
your lower abdomen, it doesn't
feel good.
There is a front wall of the
vagina which supports the bottom
of the bladder.
But you can see that the hole
that the bladder drains from is
a separate opening from the hole
that opens at the vagina.
At the top of the vagina sits
the uterus.
That's also called the womb.
That's where babies grow and
where babies come out of, and
when babies come out, they
travel from the uterus out of
the vaginal canal.
So they start here and they come
out here, and that's how all of
the pelvic floor damage happens
for a lot of us.
So you know how kids always
blame their parents?
Well, I'm telling you, you can
blame your kids.
Now, on the back wall of the
vagina, there's a support, the
back wall of the vagina actually
supports the rectum.
And so if there's a relaxation
of this back wall, it can cause
problems with the rectum.
The way that the bladder works
is that it's a storage pot for
the urine that's made by your
kidneys.
And the bladder connects to a
tube called the urethra, and
there are muscles and nerves
that help control the bladder
and the urethra.
When you're ready to go to the
bathroom, these muscles and
nerves signal urine to leave the
body through the urethra.
So this is looking front on, and
you can see here, here's the
bladder muscle, and then inside
is urine, inside the bladder,
and then there's a little
sphincter down here called the
urethral sphincter, and then
there's a muscle here and that's
the pelvic floor muscle.
So the way that bladder control
works is really a coordinated
dance.
Your kidneys make urine, and
they bring it down to the
bladder through two tubes called
the ureters.
The urine arrives in your
bladder, and as the bladder wall
stretches, it sends a message to
your brain saying I'm full.
Your brain then decides what to
do.
Do you have to wait?
Do you have to go right now or
can you wait until the next
commercial?
Is this I'm full and I've got to
go right this second, or is this
I'm full and I can finish my
grocery shopping?
In order to urinate, the
urethra, that tube through which
urine leaves the bladder, the
muscle at the very end of the
urethra has to relax and then
the bladder muscle squeezes.
And so there's a coordination to
allow the bladder to empty
normally.
So your pelvic floor needs to
relax at the same time that your
bladder muscle squeezes.
That's why if people have told
you to practice your Kegel
squeezes while you're urinating,
I'm here to tell you today you
shouldn't do that because while
you're urinating, your pelvic
floor muscle should be relaxed.
We'll talk more about that in a
few minutes.
So what are symptoms of bladder
control problems?
These are things that we know.
You can either have trouble with
leaking urine or you can have
difficulty emptying the bladder.
Some people have a sudden strong
urge right before they lose a
large amount of urine, and some
people just lose small and large
amounts when they cough or
strain.
Some people don't have urine
leakage, but they feel like, my
lord, I just can't ever make my
bladder empty.
It takes forever.
I've got to do the potty dance,
and I still can't get it all
out.
So those can all be symptoms of
pelvic floor problems.
And there are two major types of
urine leakage in women.
Stress incontinence is not
incontinence when you're
stressed out.
It's incontinence when there is
stress on your belly.
So when you cough or sneeze or
laugh, there's more pressure in
your belly, and that transmit
pressure to your bladder.
And then if the urethra isn't
nice and strong, then that
increased pressure pushes a
little bit of urine out.
There's also urge incontinence
or overactive bladder.
And that's the, oh, when I got
to go, I got to go.
That's urgency.
And then there's I got to go
now, and I can't get my pants
down in time.
Or I pull into the garage, and
I'm already starting to go.
Or I put my key in the door, and
it's already happening.
I'm getting my pants down, and
it's already going.
That's urinary urgency with
leakage.
You could also just have urinary
urgency without leakage where
you're noticing that everybody
around you seems to be able to
hold their bladder twice as long
as you can.
Then there's also something
called frequency, which is when
you feel like you've got to go
all the time.
And then there's getting up lots
of times to go overnight, and
that's called nocturia.
Does anybody here have that
problem?
Does anybody have to get up more
than once overnight to go?
Okay. I'll make sure to touch on
that, if not during the
presentation, at the end, about
what to do about that.
And then there's also overflow
incontinence, which is pretty
uncommon in women but is very
common in men, which is where
the bladder isn't emptying for
some reason and so because you
always have a full bladder, you
leak.
So it's sort of like if you
imagine walking down the hall
and you've got one cup that's
full and one cup that's half
full, you're more likely to
spill the full cup.
If your bladder is never
emptying, you're more likely to
leak, and it's not really
because of a problem but rather
because you're always walking
around with a full cup.
That can happen in men because
the prostate swells and blocks
the bladder from emptying well,
and it can happen in women if
they've had a surgery to treat
urine leakage and that surgery
has been too tight and now their
bladder doesn't empty well.
There's also, the most common
one actually, is mixed
incontinence where you have a
little bit of both, and you say,
well, I don't know, doc, it's
just annoying.
I get wet.
I don't know which kind is
worse.
And then there's continuous
leakage, which could be a sign
of something wrong, like where
somehow there's a connection
between the bladder and the
vagina so that urine can leak
all the time.
Regardless of the type of
leakage that you have,
incontinence can be treated and
even cured, and you might not
even have to see a doctor.
And so what I'm going to do now
is give you six pearls for
self-management of your bladder
symptoms.
And we're going to go through
each of them on one slide, and
they're all highlighted in your
handout.
But the six pearls are these:
modify your fluid intake, do
pelvic floor muscle exercises,
practice the Knack, do bladder
training, do weight management,
and do constipation management.
These six tips can help you cure
your bladder problems without
ever ending up in my office.
Modifying fluid intake.
So every day I have patients
tell me, oh yeah, my urine
problems are fine.
If I don't drink, I'm fine.
Well, that's a problem.
We need to drink water.
Water is important.
But we need to drink the right
amount.
And the right amount sort of
depends on your body and on
whether you have other medical
conditions.
For example, if you have
constipation, you need to drink
more water to help with that
problem.
Or if you have a kidney stone,
you need to drink more water to
help with that problem.
But I also have patients in my
office who carry around a water
bottle and they're drinking all
the time and they say I run to
the bathroom all the time, doc.
And I say, okay, well, stop
drinking so much, I think we can
fix you.
So it's drinking the right
amount, and the right amount
varies, but about 1.8 to two
liters of water a day is the
right amount.
You also want to try to avoid
bladder irritants like caffeine,
tea, coffee, alcohol, artificial
sweeteners.
I always tell my patients if
it's fun, it's probably bad for
your bladder.
But that doesn't mean that you
have to cut out all these fun
things.
Figure out which ones are bad
for your bladder.
Maybe none of them are.
I know for me, if I have coffee
and then I have the window seat
on an airplane, I'm going to be
in trouble because when I have
coffee, when I got to go, I got
to go.
So I don't drink coffee before I
get on an airplane.
But that's different for every
person.
But these are a good place to
start to see if maybe if you
just cut out your tea and start
drinking water instead, your
urgency might get completely
100% better.
The second pearl for
self-management is doing pelvic
floor muscle exercises.
And these are difficult to teach
if I'm not examining you, and I
can't tell whether or not you're
squeezing the right muscles.
So I asked my pelvic floor
physical therapy colleagues,
there are specialists, personal
trainers for the pelvic floor.
They help teach you how to do
Kegels, and not just Kegels but
how to relax and contract
because relaxing is as important
as contracting.
So I asked them, how do you tell
patients to do a Kegel exercise,
to do a pelvic floor muscle
squeeze if you can't feel?
And here are some of the
analogies that they use.
One of them is pretend like
there is a straw in your vagina,
or for men pretend like there's
a straw in your anus, and you're
trying to drink water through
the straw.
It's not just a tightening but
it's a pulling up and in sucking
water through the straw.
Or imagine you're sitting on a
marble and you're trying to pick
it up with your anus or your
vagina.
I used to work with a male
doctor.
He would always tell the
patients to pretend like they
were picking up a marble with
their anus.
I said, you know, I think women
would prefer to say with your
vagina.
But for men, it really is all
the same muscles.
It's that sling of muscles that
goes from the front to the back.
So it doesn't really matter
which orifice you imagine is
sucking something or drinking or
picking up something.
The basic idea is that you want
to pull in.
And when you're doing a Kegel
squeeze correctly, nothing else
is moving and nobody else can
tell you're doing it.
So that's how to do a Kegel
exercise.
What you want to do is focus as
much on the contraction as you
focus on the relaxation.
Relaxation is really important
because if you're always walking
around like this and I tell you
to flex, you're not going to be
able to show me very much.
Whereas if you're walking around
like this and you flex, you can
really show me a good muscle.
So you want to practice as much
with pelvic floor relaxation as
with contraction.
And you want to work on
gradually increasing your
strength, your endurance, and
you're coordination.
And you want to start with three
sets of contractions, 10
contractions each, squeeze for
10 seconds, relax for 10
seconds.
Start doing them laying down.
Once you feel like you've got
that under control, do them
sitting up, and then do them
standing.
And when you're ready to
graduate, you can practice the
Knack.
The Knack is when you stand
while you rapidly contract your
pelvic floor muscles and then
you cough.
And basically what you're doing
with that set of exercises is
teaching your pelvic floor
muscle to contract when you're
coughing so that next time you
cough or sneeze, your pelvic
floor will automatically
contract.
You're teaching it just like
when people say can you rub your
belly and pat your head at the
same time and you have to
practice for a really long time
because those two things have
never been together in your
brain before but you can
practice and learn that
coordination.
That's the same idea behind the
Knack.
That Knack, that tight, rapid
contractions of the pelvic
floor, also suppresses feelings
of urgency, and we're going to
talk about that more in a couple
minutes.
This is where I want to stop and
reiterate the point that it's
okay to try to stop the flow of
urine to make sure that you're
squeezing the right muscles, but
don't make a regular practice of
doing that because remember that
those muscles should be relaxing
when you're emptying your
bladder.
Okay? All right.
The fourth tip is bladder
training.
Mind over matter, brain over
bladder.
Okay, so when you pull in the
garage and all of a sudden you
have to pee, your bladder does
not know you're in the garage.
Your bladder doesn't know you're
getting your pants down.
It's your brain, and your brain
knows that you're in the
bathroom and it's saying all
right, go ahead, we can go, we
can go.
So what you need to do is teach
your brain uh-uh, we're not
going until I say it's time to
go.
And you did this before.
You did this when you were three
years old.
You got potty trained.
You learned how to interrupt
this.
You can do this again.
But it's going to take some
effort because now everything is
like it's on autopilot.
It's doing what it wants to do.
When I was a residence, I had
the worst keyhole incontinence
because I wouldn't empty my
bladder all day, I would get
home, it'd be a 12-hour day, I'd
put my key in my front door, and
I would immediately start to
pee.
And I'd be like crossing my legs
and stumbling up the stairs.
I owned a tiny house, and I had
only one bathroom on the second
floor.
And that's why urinary
incontinence is associated with
falls because of situations like
that where you're in a hurry and
you're rushing.
So it's really important to
actually take control.
When your brain starts to send
your bladder a message, you can
intercept it.
What you do is a combination of
urge suppression, which is where
you relax and you do those
pelvic floor muscle exercises
because, remember, it's never
normal to pick up a marble,
right?
It's never normal to suck
through a straw in your vagina.
If you do those exercises, your
brain is going to know
something's up and it's not the
right time to urinate.
So you can suppress that urge by
doing that.
Then the other part of it is
distraction.
We've all been in the situation
where we really have to go to
the bathroom, and then our kid
falls down or we spill a big
glass of milk and then we pick
it up and then we go on with the
next thing and then we realize a
half hour later, oh my, I really
had to go to the bathroom.
So there really is a big part of
distraction as you're gradually
spacing out the time between
your voids.
You want to void, on average,
every two to three hours.
And, of course, that's a rough
estimate because if you're one
of those people who's always
carrying a water bottle, you
might have to urinate every hour
because you might be filling
your poor bladder.
So it all depends, but, on
average, every two to three
hours is about a normal time to
urinate.
Okay, weight management.
I wish that this was the part
where I told you the way to lose
weight without dieting or
exercise.
Unfortunately, I do not have
that secret.
But what I can tell you is that
losing 5% or 10% of your body
weight, if you're overweight,
will improve your urinary
symptoms by up to 70%.
So in order to lose weight, you
really have to consumer fewer
calories or burn more calories,
and it will make you feel better
and it is the kind of thing that
you have to commit to and you
have to do gradually over time.
Calorie counting techniques are
very helpful.
If you're somebody who goes on
the Internet or who has a
smartphone, there is a calorie
counting app called My Fitness
Pal that I use with a lot of my
patients, and it's basically the
same idea as Weight Watchers,
where you count your calories
but you don't need to look up
what calories are in anything
because this program has it all
in there.
So if you just type in or if you
scan the barcode, it pulls up
how many calories there are.
And it's a good way for you to
keep track of how many calories
you're taking in.
And it also helps you regulate
So if you're going to have a
cookie with lunch, you realize
that then you're not going to
have enough calories to have a
cookie with dinner, so you might
choose just one or the other.
The other nice thing about that
particular app is that it also
gives you more calories in your
allowance if you exercise.
So if you go for a walk, it will
add calories to how many you get
for the day.
So the name of that is My
Fitness Pal.
And there are all sorts of
things like that, but the idea
is to just think a little bit
and be a little bit more
accountable for what you're
putting into your body and how
many calories you're burning,
and that can really help your
bladder symptoms.
And then lastly, constipation
management.
You know, on the picture, all of
these things are really close
together.
So it kind of makes sense that
if your rectum is full, there's
not going to be as much space
for your bladder and your
bladder is going to leak a
little bit more.
There are a lot of things that
are part of good constipation
management.
Staying physically active is
really important, and that can
be hard, especially if you've
got a bad hip or a bad knee and
it's hard for you to walk.
Sometimes you can do walking in
water, and sometimes you can
just do pedaling in place.
There are seated pedals.
But keeping physically active
helps stimulate the bowels to
move forward.
The other important thing is to
drink plenty of water.
As we get older, this is kind of
a sick trick, our brain stops
telling us we're thirsty as we
get older.
So we don't drink enough water,
and then we get constipated.
So you need to remind yourself,
even if I don't feel thirsty, my
body is thirsty.
You need to keep water-- I tell
my patients put a liter and a
half of water in your fridge at
the beginning of the day.
By the end of the day, it should
be gone.
That's how you can make sure you
get enough.
You also want to get plenty of
fiber to help with constipation.
But this you've got to do really
gradually because if you do this
too suddenly, you'll feel gassy
and bloated and you'll say oh
that woman was so wrong.
So you've got to really do it
gradually.
There are high fiber foods are
things like beans, peas, prunes,
anything that gives you gas
probably has a lot of fiber in
it.
And people tell me all the time,
I have a salad every day for
lunch so I get plenty of fiber.
Well, a cup of lettuce has a
half of gram of fiber in it.
A cup of beans has eight grams
of fiber in it.
So you can really get educated
about what is high fiber and
what's not high fiber.
And then there are all sorts of
good fiber supplements on the
market, and it doesn't really
matter which one you use.
Just find one that you can
tolerate, and just make sure
that you increase water with the
fiber, if you're trying to treat
constipation.
If you do need to use a
laxative, the safest one to use
every day is something like
Miralax, which is not a
stimulant laxative.
It's just an osmotic laxative.
So if you need to use a daily
laxative, that's one that
doesn't have addictive
potential, and that's a good one
to use.
If these solutions don't work,
then you should talk to your
primary care provider.
Your primary care provider may
refer you to a pelvic floor
physical therapist or to a
urologist or a urogynecologist.
Pelvic floor physical therapy is
important because pelvic floor
physical therapists are actually
people who are trained in the
muscles of the pelvic floor and
also the viscera, the organs of
the pelvis.
They can help you with some of
your behavior modifications and
symptom tracking.
They can also help not just with
pelvic floor muscle
strengthening and relaxing but
also with core muscle
strengthening and relaxing.
And they can also help you get
improved awareness of your
bladder, bowels, and pelvic
floor muscles.
If you go to pelvic floor
physical therapy and that's not
enough and you ended up in my
office, what might I offer you?
I always use the analogy of
having a knee injury.
If you have a bum knee, you can
go to physical therapy and
strengthen all the muscles
around the knee or you can wear
a knee brace or you can have a
surgery.
A knee brace doesn't fix the
problem, but it stabilizes
things and your symptoms get
better, and the analogy with
urine leakage would be a
pessary, which is a little
silicon device that sits inside
the vagina and supports the
urethra, that tube that brings
urine to the outside world.
Surgery, just like a knee
surgery, you have one knee
replaced and then 10 years
later, you got to have another
or you get a bad infection and
then you got to have the other
knee replaced.
So surgery, for some people
surgery sounds like a good
answer, but surgery is not
without risk.
So you want to try these other
things before you move toward
surgery.
There are two surgeries that we
offer.
One surgery is a sling that sits
underneath the urethra, and the
idea behind how that works is
that the urethra, as we get
older and we get pelvic floor
relaxation, instead of the
urethra sitting and being well
supported, it starts to flop in
the breeze.
Kind of like when you were 20
your urethra was sitting in a
driveway, a nice, firm, strong
backdrop.
So if you try to step on your
hose in the driveway, you can
stop the water going through the
hose because you've got a nice
firm backdrop.
But then you have a couple of
kids, you go through menopause,
all of a sudden your driveway is
quicksand.
So you can step all you want on
that hose, but you're not going
to be able to stop that water.
So what a sling does or what a
pessary does or what the muscle
strengthening does is reinforces
that driveway under your garden
hose.
If the problem isn't that you
need reinforcement under your
garden hose but rather that your
garden hose used to be like this
and now is like this, there's
also a therapy we can do where
we put some bulking in.
Just like how the celebrities
get their lips pooched out, we
can pooch out your urethra.
Narrow your garden hose.
Okay? So we can take a garden
hose that looks like that and we
can inject it so it looks like
that, and then you don't leak
anymore.
So what about the other kind of
urine leakage?
The "Oh, I got to go, I got to
go."
The best treatment for that,
other than bladder retraining
and pelvic floor physical
therapy, are medications.
And there are a ton of
medications on the market for
overactive bladder.
Does anybody know which if these
medications is available over
the counter?
Anybody know?
Yeah?
>> [INAUDIBLE]
>> Oxytrol, exactly.
Oxytrol, this pink one here, is
available over the counter.
You know why I don't like that?
Which ones do you think are
safest for older adults?
Not Oxytrol.
The two that are safest for
older adults are one called
Sanctura or trospium and one
called Mirabegron.
So the over the counter one
which you could just go to
Walgreens tomorrow and buy can
have a side effect of dizziness
and confusion and it can make
you more likely to fall.
Now, if you're 45, that's
probably not a big deal, but if
you're 75, it can be a really
big deal.
So there are these medications,
most of the medications for the
bladder are called
anticholinergic medications, and
they can cause dry mouth, dry
eyes, constipation, dizziness,
blurry vision, increase your
risk of falls, but there's
Sanctura or trospium doesn't
cross the blood-brain barrier.
So it should be safer for older
adults.
And Mirabegron is in a different
class altogether and shouldn't
cause any of those problems with
dizziness or confusion or falls.
But that one can increase your
blood pressure a little bit.
So none of them are perfect.
There's not slam dunk answer,
but there are a lot of good
medications on the market, and
we can try several ones and if
you come to a doctor who's savvy
about this, we can argue with
your health insurance company to
get the ones that are safest for
you covered.
If medications don't work, we
could also inject Botox into the
bladder muscle itself to calm it
down.
We can also implant a pacemaker.
Just like you can put a
pacemaker in a heart that's not
functioning well, we can put a
pacemaker for the pelvic floor
that can help with overactive
bladder or with bladders that
don't empty.
That's called interstim or
sacral neuromodulation.
There's even a therapy we can do
where we put a needle in through
your ankle, like an acupuncture
needle, and connect it to
stimulation and do 30 minutes of
stimulation every week for a
12-week period and improve your
symptoms by 60% to 70%.
So there are a lot of options.
So if you ask somebody and they
say, oh yeah, you are getting
older, there's not much you can
do about that.
You say, "Mm-mm, I want you to
send me to somebody
who can help."
And for a woman, that could be a
urologist or a urogynecologist.
And for a man, that should be a
urologist.
For men, I'm just going to
briefly touch on the options.
There are medications that
target the shrinking-- the
prostate that's swelling.
There's also a special catheter
that sits over the penis and
catches the urine.
There's also a clamp that sits
at the end of the penis and
catches the urine.
There's a surgery to decrease
some of that extra swelling
around the prostate, and there's
even a pump that you can put
inside the urethra that you pump
up with air to stop urine
leakage and when you want to go
to the bathroom, you deflate
through the scrotum and it
empties and allows the bladder
to empty.
I don't take care of men, so I
don't know a lot about these
therapies.
I'm going to give you that
caveat.
But urologists can help you with
all of those therapies if you
know a man who has these issues
and has tried the simple
modifications and still needs
more.
I'm now going to transition to
bowel control.
50 million US women over the age
of 40 experience accidental
bowel leakage, ABL.
That's one in five women have it
occasionally, and one in 12
women have it on a monthly or
more basis.
Less than 30% talk to their
healthcare provider.
And this is actually my big
focus and my research is about
identifying why it is that we
all think that everybody's got
urine leakage but nobody thinks
anybody else has bowel leakage.
The bowel continence mechanism
is a little bit more
complicated.
Now remember, we are talking
about if this is one of those
same pictures where the pubic
bone is here, the bladder is
here, the vagina is here, and
the rectum is right here and the
anus is right here.
Just like with the bladder,
there are muscles and nerves in
the rectum and anus that hold
stool, let you know when the
rectum is full, and signal when
to release stool.
And there are pelvic floor
nerves and muscles that work
together to help with bowel and
gas control.
However, with the bladder, it's
a little bit more simple.
With the bladder, remember the
bladder stores urine that's made
by the kidneys, and as it
stretches, it sends a message to
the brain and says I'm full.
Now, the rectum can't just send
a message saying I'm full
because the rectum can be full
with lots of things.
The bladder only ever has urine
in it, but the rectum could have
gas, it could have formed stool,
it could have loose stool, and
so you need a way for your
rectum to communicate to your
brain what's in your rectum and
how much time do you have.
And so there's a complicated
mechanism when stool arrives in
the rectum, there are two little
trap doors called the internal
sphincter and the external
sphincter.
So when anything comes into the
rectum, the internal sphincter
opens and the external sphincter
closes to allow some of the
contents of the rectum to stay
right in this anal canal, which
is really less than two inches
long.
But those little stars represent
the special nerves that have the
ability to distinguish solid,
liquid, or gas and send that
message up to our brain.
The anal canal sends the message
to the brain about what's in the
rectum, and the brain decides
what to do.
Oh, that's just gas.
There's nobody around.
I'm just going to let it out.
Or ooh, I got to go right now,
that can't wait.
And in addition to those two
muscles, there's also this
muscle called the puborectalis,
which goes from the pubic bone
and wraps down around the rectum
and helps keep this at a nice L
shape.
You can imagine if this muscle
got injured from radiation or
surgery for prostate disease or
from a traumatic childbirth,
then the line instead of being
an L shape would end up being
more of a straight line, and
then it would be even easier to
lose stool or gas.
Bowel control problems can
include accidental loss of gas
or bowel contents, chronic
constipation or diarrhea.
And if you have problems with
chronic constipation or
diarrhea, it's important to let
your primary care doctor know
because remember that changes in
stool can be significant and can
suggest something else going on.
But they also just happen with
what we drink and with our level
of physical activity so they
shouldn't be cause for alarm but
they should be cause to discuss
it with your provider.
There are four pearls for
self-management of bowel
control.
And the last two are similar to
the bladder ones, but the first
two are a little bit different.
One is modifying stool
consistency.
Two is tracking your symptoms.
Three is pelvic floor muscle
exercises And four is weight
management.
Modifying your stool
consistency, we've talked a lot
about fiber already today.
For both constipation and
diarrhea, fiber helps.
If your stools are too loose,
fiber bulks them up.
If your stools are hard little
pellets, fiber pulls water into
them.
The secret is whether or not you
use water with your fiber.
That's how you control what
happens with your stools.
You need to drink plenty of
fluids as you fiber supplement.
If you have accidental bowel
leakage, you should avoid spicy
food, caffeine, and anything
else you identify as triggers.
Some people identify wheat as a
trigger for loose stools or milk
products or olestra or
chocolate.
If you identify foods that are
triggers for you, avoid them.
If you suffer with constipation,
avoid starches that can bind you
up, like white rice, bread, and
pasta.
The second step is tracking your
symptoms.
I can't tell you how often I
talk to my patients about stool
type.
This is on my new patient
questionnaire Type one is little
rabbit pellets.
Hard to pass, straining.
That's really constipated.
Type seven in entirely liquid.
That's you ate something bad in
Mexico and it's just rushing
out.
And then there's everything in
between.
The easiest type of stools to
hold on to are type three or
four.
That makes sense, right?
If you imagine trying to hold
liquid in your cupped hands,
it's a lot harder than trying to
hold something that's well
formed.
And similarly, tiny little
pellets can also slip out pretty
easily.
So a big part of bowel leakage
control has to do with
optimizing your stool
consistency to make it a type
three or four that's easy to
hold on to.
You can keep diaries of what you
eat and drink and how that
impacts your stool consistency
to figure out what it is you
need to do to get your stools to
where they need to be.
Pelvic floor muscle exercises we
already talked about.
It's the same.
Remember, those muscles go from
the front to the back, so it's
not separate muscles.
It's all the same muscle.
Doing your pelvic floor muscle
exercises will help with both.
The other thing you want to try
to pay attention to if you have
bowel leakage is see if you can
identify when things are coming
to your rectum.
It's not something we ever
really pay attention to, but if
you can start to identify that,
if you can become mindful of
that, then you can tighten that
external trap door which over
time might get weak so that the
internal door relaxes but the
external door doesn't contract
and then you can have a leak.
But if you can get a sense of,
oh, stuff is coming on now, and
you tighten, you can stop that
external trap door.
Lastly, weight management again.
You got to diet and exercise in
order to change what your body
weight is.
I also want you guys to know
about butterfly body liners.
Anybody who has bowel leaks,
these are helpful to know about.
These are, lots of people with
bowel leaks tuck a little bit of
toilet paper inside the opening
of the rectum so that they can
catch those little leaks before
they get to the bathroom.
This is a paper product that
actually adheres to the inside
of your bottom so that it puts
the solution where the problem
is and it doesn't migrate and
it's not ever going to end up
coming out of the bottom of your
pant leg because it just stays
right there.
So this is a really nice
product.
It's the only thing.
There's an entire aisle for
urine stuff, but there's really
not very much for bowel stuff.
This is available at Walmart and
Target, but it's a small company
so you can't get it in
Walgreens.
I think it's going to be in CVS
soon, but right now for sure you
can get it at Walmart and Target
if you do have bowel leaks.
If these solutions don't work,
you should talk to your primary
care provider who, again, may
refer you to pelvic floor
physical therapy or a
gastroenterologist if you're
having changes with stool, a
colorectal surgeon if it seems
like you might have hemorrhoids,
or a urogynecologist, somebody
like me.
And if your primary care doctor
says, "There's not much
you can do about that,"
say no, "I actually don't
think that's true."
"I think there are things
you can do about that,"
and ask for a referral
because the truth is
that doctors are people just
like everyone else and we don't
all know all of the, we can't
stay up to date on everything
under the sun.
So if you feel like you get up
the nerve to ask your doctor and
your doctor doesn't have the
answer, just ask for a referral.
The additional treatments for
accidental bowel leakage will
first tell you to fiber
supplement.
We'll talk about skin care.
If you have bowel leaks, then
you probably need to be doing
some skin care just like you
take care of a baby's bottom.
With our babies, we're so
careful.
We use wipes.
We pat. We never scrap.
We put Desitin there to keep
everything from getting a rash.
And with us, we don't tend to
dote on our skin the same way,
but it's the same sensitive
skin.
So if you have problems with
bowel leak, skin care is
important.
There's also an office procedure
we can do where we put some
bulking material right in that
anal canal, that last inch and a
half between the rectum and
where you have your bowel
movements from, and we can bulk
that up just like the bulking
for the garden hose.
We can do the same bulking for
the rectum.
We can also do that pacemaker.
You know how I told you about
the pacemaker for the bladder,
if your bladder doesn't empty or
it empties too much?
That same therapy works for the
bowels.
If there's a focal injury to the
anal sphincter, that can be
fixed surgically, but that's
almost never the answer for
bowel leakage in an older adult
because it's almost never just a
problem with your sphincter.
So if somebody tells you that
that's the solution, you want to
ask for a second opinion because
probably a better solution is
one that targets more things in
the diagram.
And last of all, we're doing a
study right now testing a
pessary for bowel leakage.
It's only been tested at a few
sites, and we got selected as
one of the 12 sites across the
country that are going to be
testing it in a larger study.
So if you do have bowel leakage
and you're interested, keep an
eye out.
We'll be announcing recruitment
for that study next month.
I'm going to close with a little
bit on pelvic organ prolapse.
Pelvic organ prolapse is
relaxation of the walls of the
pelvic floor, and about half of
women between the ages of 50 and
80 have some form of prolapse.
So who's at risk?
The same people who are at risk
for all these other things.
Being postmenopausal, giving
birth one or more times, being
overweight, smoking cigarettes,
being constipated, having
chronic lung disease.
So what is prolapse?
The pelvic floor muscles and
ligaments are stretched or
become too weak to hold the
organs in their correct position
in the pelvis.
As it progresses, women can feel
bulging tissue protruding
through the opening of the
vagina.
The most common is dropping of
the front wall between the
vagina and the bladder, and
that's called a cystocele.
The second most common is
dropping of the back wall, which
allows the rectum to pooch into
the vagina.
And the least common is dropping
of the uterus, or, if you've had
a hysterectomy, dropping of the
vaginal cuff, the top of the
vagina.
Symptoms include pressure and
heaviness, bulging, feeling a
lump or a lump that comes out
beyond the opening of the
vagina, difficulty starting your
urine stream or having a slower
urine stream, problems with
emptying your bowels, chronic
straining or needing to push
inside.
And the treatments for prolapse
depend on how much it bothers
you.
Prolapse is not life
threatening, but if it's
bothersome, treatments can help
improve your quality of life.
I feel like probably 10% of
women who come to see me for
prolapse came because their
daughter saw the bulge and said,
"Oh my god, you've got to
get in... you've got to
see somebody about that."
And the patient says, "Yeah I've
had it for 15 years, it really
doesn't bother me."
Okay, all I can do is make that
patient worse.
Okay? But some people have a
bulge that's just the size of an
egg, and they're extremely
bothered.
Some people have a bulge the
size of a grapefruit, and it
doesn't phase them.
So it's all about what the
symptoms are for you.
If it bothers you, there are
things we can do.
If it doesn't, you don't need to
do anything about it.
The conservative approach is to
watch and see how things go.
Make some dietary changes so
that you're not so constipated.
Do pelvic floor muscle
exercises.
You can wear a pessary, which
you saw a picture of earlier, to
support the walls of the bladder
and the vagina.
You can also have a surgery, but
every woman's situation is
different and there's no single
operation that's right for every
patient.
The specific type of surgery
that's right for you depends on
your body, your overall health
and other health problems, what
other surgeries you've had,
whether or not you're sexually
active and plan to be in the
future, and the experience and
training of the surgeon that you
go to see.
The goals of surgery are to
restore normal anatomy, reduce
the bulge, and improve your
quality of life.
And the success or failure of
someone else's operation should
never be the deciding factor for
you.
You and your doctor together can
make a decision about what's
best for you, and it's never
wrong to get a second opinion,
if you feel like this is a big
decision.
I want to close with a couple
points.
I don't want you to be
embarrassed because you're not
alone.
Bowel and bladder control
problems and prolapse can be
upsetting and embarrassing.
They are very common, but they
are not a normal part of aging
and you don't have to live with
them.
You're not the only one who has
them, and if these pearls that
we talked about today for
self-management are not enough,
talk to your doctor.
You don't need to live with
these things.
If they don't bother you, for
sure you can live with them, and
you don't need to be subjected
to risky treatments.
But if they bother you, we
actually have a lot of
treatments available.
I work at UW Hospital in the
Women's Pelvic Wellness Clinic.
There are a total of three of us
who do pelvic floor care: Dr.
Giles, Dr. McAchran and myself,
and we have twice a month a
multidisciplinary clinic where
we actually have pelvic floor
physical therapists in our same
space.
And we can also have colorectal
surgeons and nutritionists come,
if we think that you need those
things as well.
We're also really lucky in
Madison to have three great
pelvic floor physical therapy
groups.
There are groups at Meriter, UW,
and a private group in town
called Capital PT, and I've had
the pleasure of working with
these teams of women for the
last year and a half that I've
been here, and they're really
phenomenal.
So even if you live elsewhere,
other than Madison, there's a
website you can go to, which is
APTA.org, American Physical
Therapy Association, I think,
and you can search by your zip
code and by the specialty of
women's health to find pelvic
floor physical therapy near you.
But we're lucky at Madison.
I've actually never worked in a
city that has so many pelvic
floor physical therapists.
I want to close with a quote by
a woman who participated in one
of my focus groups for my
research.
What she said was, "Why do we
not talk about this?
People don't talk about sex or
dying, and those are the two
things almost every human does.
You know what I mean?
I think it would be a nice thing
to see talk to your doctor about
incontinence, bladder and bowel
or something, a big poster in
every doctor's office.
Just bring it out of the closet.
I didn't even know I had mine in
the closet until I'm obviously
so upset about it and I must
have."
So it's hard to talk about these
things.
Not for me.
This is all I talk about every
day.
Clearly, I'm comfortable.
But I understand this can be a
sensitive issue to talk about.
And if you do bring it up with a
doctor and you don't feel like
you get the answers you need,
push because not all doctors
know what to do, but there are
doctors who can help.
Thank you very much for
listening and I welcome your
questions.
[APPLAUSE]