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We tackle the important topic of urinary incontinence with Sarah Boyles, a urogynecologist. Join us as we explore the often overlooked but impactful effects of urinary incontinence on individuals’ quality of life, its prevalence across different age groups, and the associated mental health implications. Sarah sheds light on the economic burden of this condition and discusses various treatment options available, providing valuable insights for both patients and health care providers. We also delve into strategies for addressing urinary incontinence sensitively and effectively, ultimately aiming to empower patients and enhance their overall well-being.

Sarah Boyles is a urogynecologist.

She discusses the KevinMD article, “Urogynecologists tackle the stigma of incontinence.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Sarah Boyles. She’s a urogynecologist. Today’s KevinMD article is “Urogynecologists tackle the stigma of incontinence.” Sarah, welcome to the show.

Sarah Boyles: Thank you so much. I’m happy to be here.

Kevin Pho: So we’re going to talk about your article in a little bit. First off, briefly share your story and journey.

Sarah Boyles: So I’m a urogynecologist. I think urogynecology is an unknown specialty to a lot of people. It’s been board certified since 2013, but a lot of people haven’t heard of it, including patients and physicians.

And it is a hybrid between urology and gynecology. Most people who are urogynecologists train in OB/GYN residency, although you can track through urology as well, and then a fellowship. And we deal with the female pelvis and things that functionally go wrong. So urinary incontinence, fecal incontinence, pelvic organ prolapse. I would tell you all the things that nobody wants to talk about. Frequently when people ask me what I do socially, it is a very quick way to end a conversation.

Kevin Pho: So walk me through a typical day in your professional life as a urogynecologist.

Sarah Boyles: So it really depends on the day. I spend a lot of time in clinic talking to women about their issues, and I spend a lot of time doing surgeries as well. So probably 50 percent of what we do is conservative management. A lot of it is education. People don’t understand their anatomy particularly well, it’s something that we don’t really like to talk about, so a lot of it is education, sending people to pelvic floor physical therapy so that they can kind of improve their problems in a conservative manner, medications, some procedures, and then there’s a lot of surgery involved as well.

Kevin Pho: All right, so one of the issues I’m sure that you see often is the issue of incontinence, and your KevinMD article talks about that, “Urogynecologists tackle the stigma of incontinence.” Now, for those who didn’t get a chance to read your article, just tell us what it’s about.

Sarah Boyles: So a lot of women have incontinence. It’s something that we don’t like to talk about, there’s a lot of shame associated with it, and it is traditionally something that women bring up and is kind of pooh-poohed, right, where we treat it like it is normal, and it is in fact not normal.

It leads to decreased quality of life. Women are less likely to be social, they’re less likely to be physically active. I mean, it’s really common to give up tennis or running if you’re leaking while you’re doing those things. And to age gracefully we need to be physically active and social. So it actually can lead to a lot of negative health consequences down the road. It can lead to an increase in hospitalizations and falls and fractures over time. And it is easier to treat when it is a small issue.

And so I think rather than ignoring it, it’s a super important thing to address. And I think when somebody brings it up to you clinically, they bring it up very reluctantly, they bring it up in kind of a shy manner, and there’s just a whole host of things behind that very simple sentence, hey, I’m leaking a little bit. So I think it’s really important to validate it and point them in the right direction.

Kevin Pho: So I’m going to assume that the patients that you see with urinary incontinence, they’re a lot of times referred from a primary care doctor. So typically the patients that you see in front of you who come to you for your incontinence, how do they present when you see them in the office?

Sarah Boyles: So I think we all think that incontinence is a little old lady problem, and I would tell you that that is not true. So 10 percent of women leak their entire lives, and that’s true even as a teen.

So I see a certain number of young patients who are very physically active, are volleyball players, or are doing high impact sports, that are dealing a lot with leaking. We see a lot of women after pregnancy and delivery who are having problems with leaking and just really aren’t sure what to do and how to gain control of their body and their functions. And then we see a lot of patients who are in the perimenopausal, menopausal area too. With decreased levels of estrogen you can definitely get more leaking, and so sometimes it can be a symptom of that period as well. And then we see older women as well. So it really depends. I mean, there’s a huge gamut.

And I think, because people are starting to talk about it a little bit more, I see a lot of people these days who present because it’s interfering with a sport or an activity that they want to do. I mean, one of my favorite stories is, recently I saw a woman who was about 63, and she was starting to do a lot of powerlifting because she wanted to keep up with her grandkids. She had this goal of being super active, and it was inducing a lot of leaking. She had a little bit of leaking, but that activity made it much worse, and so she wanted to treat it so she could lift. And I think that’s a great story, because we don’t think a lot about 63 year old women wanting to lift, yeah, but they should be lifting.

Kevin Pho: So there are obviously different causes of urinary incontinence. So take me through your diagnostic thought process. What kind of questions do you ask your patients to help determine what the etiology of their incontinence is?

Sarah Boyles: So you are correct, there are different types of incontinence. Most incontinence you can diagnose based on history.

So there’s stress incontinence, which is leaking with coughing, sneezing, exercise, and that is usually caused because the urethra just can’t hold in that increase in abdominal pressure.

There’s also urgency urinary incontinence, which is on a spectrum of overactive bladder, and that is when you’re having urgency, frequency, sometimes nocturia. So you feel like you’re going to the bathroom all the time, and then sometimes it’s so urgent that you’ll actually start leaking before you get to the bathroom. Traditionally stress incontinence starts a little bit younger, and urgency incontinence tends to start more in the perimenopausal period, but you can see it at any point in time.

And then there are some patients who don’t empty well, and that can lead to a lot of different leaking symptoms. If you don’t empty well, and it’s because of kind of a neurologic reason, a lot of times women won’t realize that. And so that’s one of the important things that we always check in the office, is just making sure that you’re emptying OK. Because if you’re not emptying well and you don’t realize it, the history isn’t reliable. You don’t have the sensation to describe those symptoms.

Kevin Pho: So there’s a connection between urinary incontinence and obesity, and of course obesity has been a more prevalent issue today. So talk about that connection.

Sarah Boyles: Yeah, so that’s definitely true. And so obesity can lead to more stress incontinence, it can lead to a little bit more urgency urinary incontinence, but it definitely leads to more stress incontinence.

And so the beautiful part of that is that weight loss will improve incontinence. So it improves all types of incontinence, but stress incontinence more than urgency incontinence. And so sometimes that is an extra motivator for women.

A lot of the studies on incontinence and the prevalence of incontinence have been done in Scandinavia, and they are typically a more fit country than we are, and so the thought is that the prevalence is even higher in the United States because of our rates of obesity. So yeah. But I would also say that thin women leak too.

Kevin Pho: You also draw a connection between urinary incontinence and mental health, specifically to increased risk of depression. So can you talk more about that?

Sarah Boyles: Yeah. So women who have urinary incontinence are more likely to have increased levels of anxiety and depression. And sometimes that can be causative, sometimes it can just worsen those symptoms.

I think that it’s really hard to feel like an active, vivacious, beautiful member of society when you’re leaking, and so it definitely triggers those symptoms. It becomes particularly significant if you’re limiting social activities or activities that you love. So many people treat their mental health with exercise and really use exercise to control it, but then if exercise is causing you to leak more, then you’re less likely to exercise. And so it just all becomes a vicious cycle for women.

Kevin Pho: I’m a primary care physician. How would I know when to refer a patient to a urogynecologist like yourself?

Sarah Boyles: So I think that’s an interesting question, and I would tell you that pre pandemic, a lot of the primary care physicians who were referring to me would send the patient to physical therapy first, would try a couple of medications, would do kind of an initial workup.

I think at this point in time our health system is in flux, and I would say you can send that patient to me at any point in time, and that is perfectly fine. A lot of people come to my office just looking for education and wondering what the options are out there.

And from my perspective, if I can see someone, if I can educate them, if I can send them to pelvic floor physical therapy and I can get them better with that, and then they have tools that they can use throughout their life, then that’s a win. I don’t expect my practice to be 100 percent surgical.

And I think for me the most important thing is validating those symptoms and talking to women about them, making them realize that they’re not the only person. There are a lot of women who come in and think that they’re the only person who’s leaking, and that’s not true at all. And so I think all of that, improving that dialogue and getting people to talk about it, is important. So I’m happy to see patients at any point in time.

Kevin Pho: So talk to us about some of the non-surgical options. And we could talk about surgery later on, but in terms of patients who present to you in the clinic, and you mentioned this earlier, what are some non-surgical options that you would typically discuss with them in that first visit?

Sarah Boyles: Yeah, so it depends on if it’s just stress incontinence or urgency incontinence, but with both of them, pelvic floor physical therapy and muscle training is really the first line of therapy. And strengthening your pelvic floor, and it’s not just strengthening, it’s using it correctly. So making sure that you’re breathing at the right time, that you’re using the reflexes at the right time. If you have a strong pelvic floor but it’s not contracting at the right time, it’s not really going to help you. And then making sure that you’re kind of using the correct ergonomics. And relearning those things can be difficult, but if you really engage in that, 60 percent of women will have a cure from their incontinence.

So we always start there. Weight loss is also an important thing, managing constipation, managing risk factors. So if someone has uncontrolled asthma or allergies, getting those things under control to improve the leaking will help.

For stress incontinence, we often give women pessaries. So a pessary is a device that fits in the vagina that puts pressure up on the urethra and will minimize leaking. Some people hate this idea. I think we should think of it as kind of an additional athletic support device. If you leak when you run, and then you use this piece of equipment and you don’t leak, then that is a great thing and an easy way to treat it.

There are fillers for the urethra, you can do an injection and that can stop leaking. And then traditionally the surgery for stress incontinence is a sling, where you’re putting something underneath the urethra to resupport the urethra. And slings work well. We don’t really like to do them in women until they’re done with their childbearing, because it can undo that surgery. But surgery is the most extreme treatment, or the most aggressive treatment, and not everybody’s ready for that. If you come to my office, it doesn’t mean that you’re signing up for a surgery.

For overactive bladder or urgency incontinence, we definitely want you to do pelvic floor training. There are a lot of behaviors that you can change. From my perspective, and you might totally disagree with this as a primary care provider, but we’re kind of a society of overdrinkers. I mean, everybody’s walking around with their big Hydro Flask. And so a lot of times I’ll have patients do a voiding diary, where they write down what they’re drinking, and they realize that they have this issue after they drink 60 ounces of sparkling water, and just eliminating that kind of eliminates the problem. So a lot of it is kind of that education.

There are medications for overactive bladder that you can do, and then third line treatments include things like injecting Botox and different nerve stimulators. So there’s a sacral nerve stimulator that you can implant, and then you can also stimulate the tibial nerve on the ankle, which will help with overactive bladder.

Kevin Pho: What percentage of urinary incontinence cases can be successfully treated with non-surgical options?

Sarah Boyles: I think it depends on when you’re seeing them, and kind of where on the spectrum you’re seeing them. If you’re seeing them early on, I think it’s a good 60 to 70 percent. And incontinence is very much a quality of life issue. Not everybody expects to be 100 percent dry, but they want it to be much more manageable for them. And so I think 60 to 70 percent of the time you can definitely treat it conservatively.

Kevin Pho: We’re talking to Sarah Boyles. She’s a urogynecologist, and today’s KevinMD article is “Urogynecologists tackle the stigma of incontinence.” So Sarah, as we were alluding to before this started, you’re probably the first urogynecologist I’ve had on the show. We’ve had over 1,300 episodes. So for those medical students or people in training who may be listening to you, what are some questions they should ask themselves if they want to consider a career in urogynecology?

Sarah Boyles: Yeah, so you have to be comfortable talking about things that people aren’t comfortable talking about, and there are a lot of women that have embarrassment about these issues.

I think one of the most important things, so I love what I do, and one of the reasons that I love what I do is I love the demographic that I work with. I love working with women. I do see a lot of younger patients, but in general my population is just a little bit older, and it is a delightful group of women to work with. So if you’re someone who really wants to work with men or wants to work with a lot of kids, then it’s not a great choice for you.

And there is a lot of job satisfaction, because I have people that come to me with these horrible, embarrassing problems, and then I get to fix it. And so that’s a little bit of a personality type. I’m not very good at chronic management of things. I want to help people get better and then have them go about their way and not have to worry about that issue. And so I think that that has to appeal to you. But I mean, I think the best thing about urogynecology is our patient population.

Kevin Pho: And my final question, Sarah. Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Sarah Boyles: Yeah, I would say, if someone comes to you and says, hey, I’m leaking, don’t minimize it, don’t laugh. Validate those symptoms, say, yeah, lots of women have that. And it may seem like a little problem, but it can lead to some big things. It can lead to mental health issues, it can lead to decreased quality of life, and so it’s an important thing to address.

I think a lot of people are super busy in their clinical practice. It doesn’t mean that you have to address it, because it can involve a long conversation, but you should know your local resources. Or, I have a website and I have some resources on my website to help women get started with incontinence, at thewomensbladderdoctor.com. And I just think it’s important to validate it and say, hey, you’re not the only one, and look in this direction to get better.

Kevin Pho: Sarah, thank you so much for sharing your perspective and insight, and thanks for coming on the show.

Sarah Boyles: Thank you.