E33: 7 Domains of Bladder Health

Check, check. Oh, maybe I better hit the potty before I start this podcast on the bladder. Is that just me? Well, bladder problems are not just me. And today we're going to talk about the 7 Domains of Women's Bladders. Part of this is in response to a very funny "Who Cares About Men's Health" podcast from The Scope on men's problem with their stream. When they pee, men worry about their stream flow, and women are more likely to worry about stopping their bladder flowing.

We're going to get to it, but if talking about your bladder makes you . . . you know . . . you can pause now, hit the potty, and then rejoin us.

Many women have problems with their bladders, and the most common problem is incontinence, leaking when you don't want to. Of course, we all started with this problem when we were babies, and we'll probably have this problem more sometime in our life. So let's get to it.

Helping us in the virtual Scope studio is an expert on women's bladders, Dr. Carolyn Swenson. She's an Associate Professor in the OB/GYN department at The U, the University of Utah, and she is Chief of the Division of Urogynecology, which is a group of OB/GYNs and researchers with specialty training in women's bladders and their pelvic floor.

Dr. Jones: Thanks for joining us, Dr. Swenson.

Dr. Swenson: Thank you for having me.

Dr. Jones: Now I have a question. What were the factors that directed you to this field of work? I mean, we think of OB/GYN as being babies and fibroid tumors in the uterus, but you took a different path.

Dr. Swenson: Well, what attracted me most to the field of urogynecology was the ability to make a huge difference in improving women's quality of life. So urinary incontinence and prolapse are symptoms and conditions that have been around for as long as women have been having babies, so for thousands of years.

But despite that, our field is actually a relatively new field. So when I was in my residency training, our field was actually just getting our accreditation and gaining more exposure as an actual subspecialty of OB/GYN, and that was exciting.

I loved the ability to help women with these conditions, which sometimes are really difficult to talk about and patients are uncomfortable with. And just getting to see the improvement in women's quality of life is the best part of my job. So it was just kind of a natural fit for me.

Dr. Jones: I belong to a clan of leakers, and so I'm grateful for people like you who can help my whole clan. Now, full disclosure, and we don't have to keep this on the tape, have you ever lost it?

Dr. Swenson: Absolutely. So I have three children of my own. And after every delivery, I struggled with urinary incontinence. It's common. It is something that most women at some point in their life will experience. And so yes, I have definitely been somebody who's had struggles with leakage of urine.

Dr. Jones: Okay. Well, that normalizes it for all of us who are listening. You belong now to my clan.

Dr. Swenson: I'm in your clan.

Dr. Jones: The clan of the leaking ladies. Well, you've published some research on older women and bladder problems, specifically incontinence. Can you talk a little bit about that, your survey?

Dr. Swenson: Sure. So when I was at the University of Michigan, they are part of a really fantastic group that runs the National Poll on Healthy Aging, which is actually sponsored by the AARP. They do some really interesting work on conditions that affect particularly the older population.

And I approached the lead investigator for the National Poll on Healthy Aging about doing something specific to women, which they had never done before. So we were able to do a national survey on women ages 50 to 80 about urinary incontinence.

And so what we found was really interesting. Almost half of women have experienced urinary leakage in that age group. And of those women, a third of them have leakage on a daily basis, which is pretty significant.

The other interesting things we found out in the survey was that a large proportion of women actually haven't talked to their doctors about leakage of urine, even those who have daily leakage.

Their leakage of urine also really impacted their quality of life. Many women reported limiting their activities, not going out shopping, or going to the movies, or doing things with friends that were outside of the house because of concerns of leakage of urine.

So the take-home point from that was that it's common in older women. It can be quite severe, and women limit their activity because of it, and not everyone is talking to their doctors about it. I think a lot of the reason behind that is because they kind of assume that leakage is a normal part of aging and there's nothing that can be done, and so they just kind of have to live with it and suffer with these symptoms. And fortunately, that's not true. We have lots of good treatments for leakage of urine.

Dr. Jones: Well, we talked before on the "7 Domains" about what's normal. And I would say if you define normal as something many people have, more than 5%, then you'd say that this is normal, but not desirable. It's common, but not desirable to be in the Leaking Ladies Club.

So now that we decided it's a really big club and the Association of Retired People helped you put this really amazing survey out, let's go to the physical domain. We get control of our bladder between 2 or 3 years on average. I think there's some data that says that girls hold it better than boy babies. That's just on average. But we do pretty well until, I don't know, we get with a bunch of girls. I always think of teenage girls saying, "I laughed so hard I peed my pants." What's that about?

Dr. Swenson: There was a little sign that I saw in one of these home goods type stores that said, "I laughed so hard tears ran down my leg."

Dr. Jones: I love that.

Dr. Swenson: I feel like that should be a plaque in our office, our clinic somewhere because that is true. That's what happens.

So yeah, that is called stress incontinence, and the reason leakage happens in those situations, laughing, coughing, sneezing, has to do with an increase in intra-abdominal pressure. So any time you do those things, the pressure inside your abdomen and pelvis increases.

To be able to hold urine in, your urethra, that little tube you pee out of that's attached to your bladder, has to be strong enough to resist that increase, or that sudden increase oftentimes, in intra-abdominal pressure. If for whatever reason you're not prepared or your urethra is not strong enough, then you have leakage of urine. So yes, that's what we call stress incontinence.

Dr. Jones: Well, you could certainly have it if you've got a really bad cough. You got COVID and you cough for a month, and you're still young and your bladder is in the right place.

I've been watching the NCAA finals in gymnastics, and those ladies don't have a micrometer to stick a little pad in their outfits, and they land really hard and they would show. So what are they doing? They are landing on their pelvic floor over and over and over for years. Is that a risk factor for a little bit of problems?

Dr. Swenson: So gymnasts, Olympic weightlifters, paratroopers, they all experience leakage of urine. Stress incontinence in female athletes is actually quite common because of exactly what we're talking about. That sudden increase in intra-abdominal pressure is just too much for the urethra, even a normal urethra sometimes, to handle.

So, the data on whether activities like gymnastics over time increases your long-term risk of urinary incontinence, we actually don't have good data to say that is the case. There is data, however, in some situations that chronic straining or chronic what we call repetitive loading, those are those activities where you just really put a lot of force on your pelvic floor over and over and over, in some studies that is associated with leakage of urine and pelvic organ prolapse.

Dr. Jones: So the other time that we have difficulties before we get very old and when we get old is when we have a urinary tract infection. What's that about?

Dr. Swenson: That kind of ties in nicely to the other type of urinary leakage, which we haven't talked about specifically yet, which is overactive bladder and urgency incontinence. And this type of leakage happens when you have some sort of irritant in the bladder or an overly sensitive bladder muscle that kind of squeezes when it maybe shouldn't, and then you leak urine associated with that.

So common situations are when you have a couple cups of coffee and you start to get that really strong urge to go and then can't make it to the bathroom, or when you drive home from the grocery store and put your key in the door and you have a sudden strong urge to go and can't make it to the bathroom.

In those situations, your bladder muscle is squeezing. That's when you get that urgency sense. That's that bladder muscle squeezing, and you just are not able to hold it in because that bladder squeeze is so strong.

With a bladder infection, it's very similar. So you have bacteria in the bladder, in your urine that your bladder wants to get rid of, and so it gets irritated and starts squeezing and contracting, and that's associated with those leakage episodes.

Dr. Jones: Right. And then we get pregnant and our baby's head sits on our bladder, but the problem or the process, it's not a problem, of vaginal birth is it rearranges or weakens/stretches the pelvic floor. Women may often have a problem right after birth, but women who have had their bladder rearranged, pelvic floor rearranged, they often get better, but then when they get into their 40s and 50s, they get a little worse. So is that an aging bladder floor, or is it an aging brain, or is it both?

Dr. Swenson: It's a great question, and it's probably a combination of both. So let's talk about the aging aspect first.

We have really good clear data showing that aging is associated with weakening of our skeletal muscles in our whole body. So after age 50, we lose about 10% of our skeletal muscle mass per decade.

The urethra, that tube you pee out of, there is a muscle that goes around the urethra that is skeletal muscle. And so that is also affected by aging. And we know from studies that have been done looking at the strength of that urethra that as you age, you also lose strength in that urethra.

The ability to hold in urine is really reliant on that urethra strength. You want a really strong urethra so that you can resist bladder squeezes and resist increases intra-abdominal pressure and hold urine in.

So aging alone increases your risk of kind of a weak urethra and leakage of urine. Then add on top of that the pelvic floor changes that come with vaginal delivery, and those kind of compound and exacerbate the aging effects.

Dr. Jones: Gravity is relentless.

Dr. Swenson: Gravity as well, yes. And that ties into the prolapse. Prolapse and urinary incontinence are related and often occur at the same time and for a lot of the same reasons.

Dr. Jones: Well, I just did 20 over the last minute. I did 20 while I was listening to you talk. I can Kegel while I talk. I'm doing it right now. You can sense a little strain in my voice maybe, but I can really make my pelvic floor contract. So is that helpful? I'm doing it now.

Dr. Swenson: I love that you are doing Kegels. You keep those up. The key is to be able to do the Kegels correctly. And so if you're not sure whether you're doing a Kegel correctly, then I would encourage our listeners to go see their OB/GYN or a primary care doctor to make sure, or if you have a pelvic floor physical therapist already, that's even better, just to make sure that you are squeezing those muscles correctly.

About 20% of women actually are not able to perform a Kegel. And that is just squeezing those pelvic floor muscles together. You really squeeze them as a group. It's hard to just isolate one, and that's okay. You want to use them all.

Kegels can be really effective at managing bothersome bladder symptoms, for both the types of leakage we talked about. So if you are somebody who is bothered by kind of that really strong urgency or leakage when you get home and put the key in the door, being able to squeeze, doing four to five Kegels right in a row, really squeezing those pelvic floor muscles can actually help relax the bladder muscle and can stop that sense of urgency.

And for stress incontinence, if you are about to sneeze or cough or laugh really hard, performing a Kegel before those things is a strategic way to help prevent leakage.

Dr. Jones: Well, this topic is great for the "7 Domains" because it is really a foundation of what we consider a normal active life. And when it goes wrong, it affects all parts of our life.

I think about the emotional domain, and for me, I think of shame. I've been married. I've been together with my husband for 50 years and I don't really have a big discussion with him. He's a modest man and I don't really want to talk about it. But what are the common emotional responses in older women? You did the survey. Maybe people talked about that.

Dr. Swenson: Absolutely. Shame is a big one. And isolation, depression, kind of hopelessness, those all go along with having urinary continence, especially if you feel like you have to limit your activities or can't go to social outings due to fear of leakage or embarrassment. That's another big one that the National Poll on Healthy Aging showed, is fear and an embarrassment of leakage.

Dr. Jones: Well, I was thinking about the podcast the men did on their streams and trying to normalize. Guys just make a big joke out of it. And I think when women get together, the leaking ladies' lunch, they can kind of joke about it. But in general, I want to normalize the conversation. You're not being degraded to a little baby who can't do it, or a toddler who's struggling. You're a grown woman, and this is common and there are things that can be done about it.

Hopefully, as we move into the social domain, we find ways that can help women get out, do stuff. Not just go to a mall where they know where the potty is, but be able to go other places. I think of the social limitations.

Dr. Swenson: Absolutely. I think what you said about increasing awareness that there are treatments for leakage of urine and that women don't just have to suffer with this. Even though it is common, there are treatments. So I think that's a really important point that you made.

Dr. Jones: Well, when we get to the intellectual domain, which is coming up in a minute, we're going to talk about treatments. A lot of women don't seek help and they just wear pads. In the financial domain, pads aren't necessarily cheap and they're not very environmentally friendly.

Dr. Swenson: You are correct. So I did a little research on the value of the incontinence care market. Do you want to take a guess? So what do you think is the value of the global incontinence care market?

Dr. Jones: Oh, gosh, I wouldn't know globally.

Dr. Swenson: Well, by 2026 the estimated value is over $24 billion.

Dr. Jones: Oh, gosh.

Dr. Swenson: And the vast majority of that market share is absorbent products like pads and incontinence underwear. That's a new thing that's really gained a lot of popularity.

Dr. Jones: Does that work? Do they work?

Dr. Swenson: I've had a couple patients use them. I don't have a lot of people. I mean, they're kind of expensive.

Dr. Jones: Yeah, I checked them out.

Dr. Swenson: They're expensive. I think they work for small leaks, but . . .

Dr. Jones: Yeah, teeny leakies. I wouldn't trust them to go on a hike.

Dr. Swenson: But again, I think the incontinence, my problem with this . . . Obviously, we have to have something to help women manage the leakage so that they can go out and live their lives and not have concerns about having embarrassing incontinence episodes while they're out in public. But I also think kind of the message that is driven with all of these commercials and marketing towards incontinence products is that this is the answer, right? Like, "This pad is the answer to your leakage of urine."

And that is, again, pushing the narrative that women just have to live with this. "You're going to leak, there's nothing you can do about it, you might as well just buy this pad that will help protect your clothes," instead of saying, "You have leakage, go see a urogynecologist and get some treatment for this so you don't have to use pads."

Dr. Jones: Then we're going to get right down to it, and in the intellectual domain, we're going to talk about learning about what kinds of things can be done, and I'm going to stick environmental domain in there.

So we decided we have a problem and we've had it. We've talked a little bit about the causes and that women don't want to talk to their clinicians about it, but what are the solutions? What are some of the solutions?

Let's talk about the solutions of the irritable bladder, the bladder that just wants to go all the time. Can our mind control that? You talked about doing some Kegels when it happens, doing some squeezes. Can our mind help control this too?

Dr. Swenson: Absolutely. So we have a lot of great treatments for both types of leakage that we've talked about. But if we're talking about kind of the overactive bladder symptoms, urgency, and frequency, the mind has a huge role to play in the treatment of this urinary urgency.

There's actually some interesting research looking at brain imaging in patients who have overactive bladder and bothersome urinary urgency. It appears as though women with those symptoms kind of process bladder filling in a different way and that it is associated with negative emotions.

This could be because in the past they've had leakage episodes and there's a strong fear of leaking, and so that bladder filling, which is normal, our bladder is filling all the time, is associated with negative emotions, and therefore that's interpreted as discomfort or we want to get rid of that negative feeling. So we try and go to the bathroom and empty our bladders.

The bladder responds really well to mental signals, so signals from our brain, and the bladder is a very habit-forming organ as well. So there are lots of things we can do mentally to help retrain our bladder to be less irritable and more cooperative and kind of work with us a little bit better.

So one strategy is if you are . . . again, going back to the scenario where you get home from the grocery store, you put your key in the door, and have a really strong urge to go. Let's say you emptied your bladder like 45 minutes ago, so you know your bladder is not really full, but it's giving you the signal that it needs to empty. One strategy is to kind of think about something else. So do something that requires some thought.

I often tell patients . . . give them an example of counting backwards from 100 by 7s. At least for me, that would take some mental energy to figure out how to do that. And just distracting your brain a little bit so it's not so focused on your bladder can be a really useful trick.

There's another really interesting study. Actually, Ingrid Nygaard, who is one of my colleagues and a senior urogynecologist at the University of Utah, did a study looking at mindfulness-based techniques, and that was highly effective at reducing urgency incontinence episodes. So practicing daily mindfulness stress reduction techniques actually can show some benefit too.

Dr. Jones: Well, we've talked a little bit about environment in the 7 Domains, environmental factors. I've managed to convince my husband that he has to do the dishes because my hands and running water isn't really good for my bladder. That's really an excuse because I can do it just fine, but it's working pretty well right now. So it's a twofer. I don't have to stand with my hands in warm running water and I get to watch him do the dishes. That's cool.

What about food triggers or other environmental triggers?

Dr. Swenson: So that is a really common one that you mentioned and I think your solution is a great one. I love it. So running water, arriving home, which we already talked about, cold weather can be a trigger. Sometimes kind of walking from a warm house outside to the cold can trigger an urgency incontinence episode.

But then we do have a lot of dietary triggers that maybe we don't always think about. Caffeine is a pretty common one that I think most people are aware of to some degree. So if you drink several cups of coffee or caffeinated beverages, that makes you feel like you have to pee. And so in addition to caffeine, artificial sweeteners are a big one. Alcohol, nicotine, and spicy foods.

Dr. Jones: Well, why bother living, Carolyn? Come on. No coffee, no spicy foods.

Dr. Swenson: Well, what I always tell patients is . . . And there's actually a whole list of potential triggers, but they affect everyone differently. So I'm not encouraging everyone to go eliminate all of their caffeine or artificial sweeteners or spicy foods. However, if you have bothersome bladder symptoms, then it's worth paying attention to what happens after you consume these things. If you can identify one of these triggers, it can actually make a huge difference in your symptoms.

There's one other thing I want to mention and that is overall fluid intake. This is something that I see a lot. So there is what I kind of call the hydration myth, which is that everybody needs to drink eight eight-ounce glasses of water per day. And I'm not sure who started that myth, but there is zero science or evidence to support that everyone needs 64 ounces of water per day. Everyone's fluid needs are different depending on your activity, your metabolism, the environment you live in, the foods that you eat. So I often see patients who honestly have bladder symptoms because they're just drinking too much fluid.

Dr. Jones: Yeah, everybody walks around with their water bottle, which is something that never happened. I mean, everybody's got their bottle with them. So I think this has spawned an industry of plastic water and plastic water bottles. I don't think plastic is good for your bladder, but I don't have data for that.

Anyway, let's talk a little bit about medication, because I know that there are certainly ads on TV for medication for an overactive bladder.

Dr. Swenson: Yes. So there are kind of two classes of medications. I'm not going to talk about specific names, but the one class is called anticholinergics. And both classes work by relaxing your bladder muscle. They just use different receptors. So the anticholinergics have been around for a really long time and they have good efficacy, but the limiting factor can be the side effects.

So dry mouth and constipation can be associated with these medications, and those are the two worst side effects you can give somebody with urgency incontinence/overactive bladder because then they drink more, and if you're constipated, your urinary symptoms actually get worse. Oftentimes these medications can be really helpful. Sometimes those side effects limit their long-term utility.

The other class of medication, which is a newer class, is beta-3 agonists. And again, this is a different receptor in your bladder, relaxes the bladder muscle. These don't tend to have those side effects as much, and so these medications actually can work quite well for overactive bladder symptoms.

Dr. Jones: Yeah. Now for women, we aren't talking a lot about people who've had pelvic floor problems and the dropped bladder, but if you have a dropped bladder and you're thinking it's really troublesome every time you cough, sneeze, or walk, is there something you can do to push it back up there? Can you just say, "I just want to push something back up there. It's uncomfortable and I pee all the time"?

Dr. Swenson: Absolutely. So, like you stated, prolapse and incontinence or urinary symptoms often come together. And actually, a dropped bladder, which is called a cystocele, can cause a lot of these urinary urgency symptoms. Your bladder is not happy if it's not in the right location, so pushing it back up where it should be can often help treat those urinary urgency symptoms.

And one way we can do that . . . Well, we have two ways. One way is by strengthening your pelvic floor muscles, and that would be through pelvic floor physical therapy. And then the other way is using a small device called a pessary, which is a little ring. It's medical-grade silicone. It's placed in the vagina and just mechanically holds the bladder wall back up, the vaginal wall, and the bladder is right above that. And that can be really successful in treating some of those symptoms.

Dr. Jones: But eventually, some women have significant prolapse or they just say, "I don't want to wear that thing, I just want my bladder tucked back where it's supposed to be." And that's something that you do every day. This is your specialty. You've done it thousands of times. Can you talk a bit about bladder surgery?

Dr. Swenson: Sure. So we have a lot of great surgical options for patients who kind of either have tried the conservative management and it doesn't work, or whose prolapse or leakage is so severe that surgery just is the right option for them.

It kind of depends on what your pelvic support is like, the extent of your prolapse. But we have prolapse procedures that will fix the dropped bladder and help restore normal anatomy. That's the goal of our reconstructive surgeries. And then we also have some surgical treatments for both stress and urgency incontinence.

Dr. Jones: I think that coming to a specialist can help in asking the right questions. I know that my mother in the Leaking Ladies Club had had four babies and had things tucked up, and then she got put on an anti-hypertensive in her 70s that made her cough. She was getting ready to have her second operation. I said, "Mom, did you talk to them about your chronic cough? Maybe you should take an anti-hypertensive." No one talked to her about that. So there's some medications, or a chronic cough, that's going to make all this much worse.

Dr. Swenson: Absolutely.

Dr. Jones: So getting a good history from someone who knows, I think that's helpful.

Dr. Swenson: It's not always possible to change those medications. So I'm thinking of somebody with heart failure who's on a diuretic, which just makes them produce so much urine. We probably can't change that diuretic, but if there is a medication that's causing something like a chronic cough that we can change, sometimes that's all you need and you can avoid surgery.

Dr. Jones: Right. Well, let's talk about some other sort of ancillary things. Is there a role for vaginal estrogen? We're talking about mostly older women. That was the group of women that you surveyed, and most of them are going to be post-menopausal. Does giving some estrogen for the vagina help at all?

Dr. Swenson: Vaginal estrogen is really effective for treating recurrent urinary tract infections, for restoring kind of normal architecture to the vagina, and managing symptoms of pain with intercourse that can be related to vulvovaginal atrophy or kind of thinning of the vaginal epithelium.

There is mixed data on the urgency/overactive bladder symptoms, but it is certainly worth a try. Vaginal estrogen can help with a lot of pelvic floor symptoms.

Dr. Jones: So now controversial stuff. What about this laser therapy? People have talked about rejuvenating the vagina and doing laser in the vagina. Is that helpful for bladder problems?

Dr. Swenson: Well, I first want to say that the laser is not FDA-approved for use in the vagina. And so I do not offer that to my patients for that reason. We do not have any compelling data to suggest that the laser is an effective treatment for stress incontinence or overactive bladder.

Dr. Jones: How about Botox? If I don't want my face to get wrinkled up funny, and I'm wrinkly, maybe Botox down there would help my bladder.

Dr. Swenson: Yes, Botox actually is very effective. So it is considered a third-line treatment. So it's not something that we would offer as a first-line, or something as a first step of treatment.

But with Botox, what we do is inject the Botox, which is the same Botox that's used to treat crow's feet and for cosmetic facial procedures. We inject that into the bladder muscle. This is done in clinic. It works by partially paralyzing that bladder muscle. So we talked about before how the bladder muscle is just kind of overactive and squeezes too much with urinary urgency and urgency incontinence. The Botox relaxes the bladder just enough so that you don't have those urgency symptoms. So it's actually very effective.

Dr. Jones: Well, I'm going to start a leaking ladies Botox party. You've heard of a Botox party. Let's just do one for leaking ladies. Don't you think that would be fun? I'll invite you. You can be my star of the leaking ladies Botox party.

Dr. Swenson: I would be honored to. Thank you.

As we move on to the spiritual domain, it's hard to think about the spiritual domain as having a big impact, but the concept of mindfulness, of being able to be accepting of who you are, and not spending a lot of negative rehearsals about this problem, which probably makes it worse, but coming to some grips with who you are and what can be done and self-acceptance becomes important. Mindfulness is an actual treatment to try to stop your negative rehearsals, however one achieves that through one's spiritual practice.

I don't know whether yoga works, I don't know whether prayer works, but I do know that negative conversations with yourself about this does not make it better and might make it worse.

So we've kind of been through the 7 Domains, and I want to thank you, Carolyn, for coming and joining the Leaking Ladies Club, even though you don't do it now, but you were a temporary member.

And before we sign off, I'm going to end with the 7 Domains of the Aging Bladder haiku.

Uh-oh, got to go
Cross my legs and count to 10
Smile, think grandbabies

Thanks, Carolyn, for joining us. Listen to our podcast wherever you get podcasts, and think about all of our other wonderful shows on The Scope. Talk to you later. Bye.