Introduction

Dr. Bob: And welcome to The Dr. Bob Show. For the next 30 minutes we're going to have lots of health tips for you and your health. We thank you for taking the time to come and watch The Dr. Bob Show. We think it will improve your life. We're going to be spending most of this show talking about well, a sort of embarrassing thing to some people. We're going to be talking about female urinary incontinence-very, very common. Millions of Americans have urinary incontinence and the bad part about it is a lot of people don't realize that it is so easily treatable. There're lots of things that we can do and so we're going to have lots of information for you.

I have an outstanding guest. My guest is Dr. Jeffrey Dell. Dr. Dell is board-certified in Surgery and also Obstetrics and Gynecology and is also the Head of the Institute for Female Pelvic Medicine. Lots of certificates behind that name and you're going to love Dr. Dell. He's a great teacher. Later on in the show we'll be talking about iritis. Do you know what iritis is and is it really dangerous to your eyesight? We'll be talking about tinnitus-ringing in the ears. How many of us have had ringing in the ears and we don't know what's going on there? We'll be talking about complications of too many steroids and then we'll be talking about what's best for you, diet or exercise? Can you lose weight with both or just one? We'll give you that answer.

Dr. Bob: We're going to be talking about female urinary incontinence, talking with Dr. Jeffrey Dell. Jeffrey, welcome to The Dr. Bob Show.

Dr. Dell: Thank you very much.

Dr. Bob: It intrigues me, The Institute of Female Pelvic Medicine. That's a big title. Tell me about what you all are going to be dealing with, primarily.

Dr. Dell: We're going to focus really on the entire aspect of female pelvic-floor health-urinary incontinence, bladder disease, bladder conditions that cause pain, and bladder symptoms and prolapse. So, that's what we're going to focus our entire energy on is dealing with those aspects for women.

Dr. Bob: Let's talk about incontinence. Really, is there a definition for incontinence?

Dr. Dell: Well, the definition of incontinence that's easiest to remember is any loss of urine when there's not supposed to be (and there shouldn't be very often). So, it's a very, very common problem and there are different types of problems. Probably the most common type is what we call "stress incontinence" which is a loss of urine with activity like coughing, sneezing, laughing, picking something up. Over 13 million Americans at least have that problem. Another type of incontinence we commonly call "overactive bladder symptoms." These patients have urgency and frequency. They go to the bathroom 10-15 times a day, maybe even more. Maybe two, three, four or five or more times at night. So, it's a little different type of problem but often they can't make it to the bathroom in time before there is loss of urine. Some patients have what we call mixed incontinence and that would be certain aspects of both of those conditions and then some patients have what we call overflow incontinence where the bladder doesn't empty very well. So, they're always feeling like they need to go and the bladder stays more full than it ought to and this leads to all kinds of problems. So…many different types of problems…

Dr. Bob: The most common type that you see…..

Dr. Dell: Stress incontinence is the most common type. An overactive bladder is a very common problem as well.

Dr. Bob: Now, with stress incontinence, I hear all the time, "Oh, I think it was so funny, I laughed so hard that I 'had incontinence.'" Or, "I can't go out and run because if I do, I have incontinence."

Dr. Dell: Right.

Dr. Bob: How do you handle those things? Let's talk about it…give people some hints.

Dr. Dell: I'll tell you what's interesting…of the millions of Americans who have this problems, we know that less than half ever seek help for it and the truth of the matter is that probably a third of all women over the age of 40 have some significant problems with regard to their pelvic floor anatomy and/or bladder. How do you decide whether you need to do something? I think what it really boils down to is, is it beginning to interfere with your quality of life? Are there activities that you no longer do-running, jogging, aerobics, other activities-because of the bladder problems? Do you find that it's hard to visit or shop because you're always having to find a bathroom at every store that you go to or you know where gas stations are between every point that you travel? Those are clues that it's beginning to impact your quality of life and it's probably worth getting something done about it.

Dr. Bob: Why do women have more incontinence problems than men, or do they?

Dr. Dell: Certainly they do and I think a lot of it just really comes down to the anatomy of the pelvic floor. Certainly the urethra or bladder neck in a female is very short compared to a male's anatomy. Childbirth has a tremendous role that it plays in this. The process of pregnancy and delivery through that pelvic floor puts a tremendous strain and stress on things. And so, there are certainly other genetic aspects and individual components but those are the main reasons why females tend to have a much greater problem.

Dr. Bob: When somebody has incontinence, do you treat mainly with medicines or is it development of muscle exercises, or is it surgery?

Dr. Dell: All of those things are very very important and that's why it's so important to take a very individualized approach for any given patient. The different types of incontinence that we were talking about a minute ago are best treated with different types of things just like you mentioned. And in some cases where more than one type of problem is going on, it requires more than one type of treatment. So it's very important to do a comprehensive work-up in these patients to really know what the source of the problem is. And then we can move on to talk about what the best options are for that specific type of incontinence.

Dr. Bob: Take a young person-never delivered a child, likes to run, has incontinence when they run. What's the most likely approach to treatment?

Dr. Dell: Well, that patient probably has stress urinary incontinence although it's more unusual in somebody who hasn't had babies and there's a wide variety of options. There are some medications that can be looked at for that type of problem, although we use medications less often for stress incontinence. We can fit patients with an incontinence ring, a simple little medical device that they're fully able to place themselves and to remove-a device that in many cases can completely keep them dry during all those activities. And much less often, we consider surgery in a younger person who hasn't had the childbearing years done with, but on occasion we have to look at that.

Dr. Bob: And if somebody is in their mid 40's and they've had two children and they've had a relaxed pelvic floor because of childbirth two or more times-what's the difference there?

Dr. Dell: Certainly most surgical procedures that we do on the pelvic floor with regard to incontinence, we really try to do only in the patients who are done with the childbearing years for a couple of reasons. If a patient has that type of procedure done before she feels comfortable that she is done with childbearing, we could run into quite a difficulty with recurrent incontinence, recurrent prolapse or other issues because there's not as much give in that pelvic floor and it's not designed for the baby to come through that afterward surgery. But once the childbearing years are done with, we don't have to worry about that aspect and then we have really a wide variety of things that can be looked at and tailored to the individual patient to correct that pelvic floor anatomy.

Dr. Bob: Let's talk a little bit about lifestyle changes. How about drinking fluids…the kind of fluids that we drink. Does any caffeine increase incontinence?

Dr. Dell: Caffeine has some diuretic effect. It will tend to make people go a little bit more frequently and so, very often it's helpful to have the patient keep a record for a period of about two days, carefully noting what they take in for fluids and what kinds, and also note how much and how often they go. Because, you're right, in some cases we find that patients are drinking several diet cokes a day or always have a cup of ice tea with them and that's really what's leading to it. So, sometimes simply adjustment in fluid intake can make a difference.

Dr. Bob: When a female comes into your office and says, "I've got leakage of my bladder… I've got incontinence," how do you organize your history and your evaluation?

Dr. Dell: We have the patient fill out a fairly extensive list of questions that we have for her as to when did these events occur. So, before I even get to talk to her, I have a wide variety of information that we've obtained. But then what's so important is to listen to what the patient is telling us because that's where it really comes down to the nuts and bolts of how you solve the picture. Everybody has special circumstances and certain things that have to be taken into consideration and so, once we get an extensive history and we listen to what the patient's telling us and what is really bothering her, then we typically move to a very careful physical exam and take a look at the anatomy.

Dr. Bob: And after that you can pretty much tell if they're going to need surgery, a pessary device, or just lifestyle changes?

Dr. Dell: Sometimes that's all it takes to really recommend changes. Often we have to do some special testing.

Dr. Bob: And that's what we're going to talk about. We're going to be talking about those special tests and then we're going to talk about the corrective measures that we have for your incontinence.

Patient Interview

Dr. Bob: What type circumstances did you have to be very careful about?

Patient: The biggest thing was being in public and knowing you had a full bladder. You didn't cough and you didn't sneeze, you didn't laugh.

Dr. Bob: What did you have to do about drinking caffeine or…

Patient: You learn not to drink a lot of anything, especially if you didn't know where the facilities were or how long you were going to be gone or that kind of thing.

Dr. Bob: What was the trigger? What was the straw that broke the camel's back?

Patient: I had, I just had gotten progressively worse and then one day at my desk at work, I just reached up over my head to pull a book off the shelf. So, I was sitting and had a bout of incontinence and I thought, man, you know, this is just ridiculous. There's got to be something you can do.

Dr. Bob: And what did Dr. Dell tell you?

Patient: He told me that I had a problem he could fix.

Dr. Bob: Good, Good. How did that make you feel?

Patient: I was thrilled!

Dr. Bob: Did you know he was going to say surgery?

Patient: I…I had anticipated it.

Dr. Bob: And so, what was the first thing that you were able to do?

Patient: The first thing he did was put me on some medication and that helped a lot with having to get up several times at night and the frequency and that kind of thing. But it didn't do anything for the sneezing- coughing-related wetting your pants.

Dr. Bob: And so, what did he do then?

Patient: Then we decided, after he did the cystoscope and took measurements and that sort of thing, he, we decided to do the surgical procedure.

Dr. Bob: Do the surgery procedure. Did you use a pessary at all?

Patient: No, I did not.

Dr. Bob: You didn't do that. You did the surgery-had a surgical procedure. Tell me about how excited it made you feel. I just think that's great.

Patient: It's like having a life back, to be perfectly honest. I mean, everything I did prior to having that surgery was planned around where the restroom was and how far away I was going to be from it. And I always carried extra clothes and I didn't have to do any of that anymore. I could go where I wanted to, do what I please…

Dr. Bob: We're talking about female urinary incontinence. We've talked about stress incontinence, urge incontinence, overflow incontinence and now we want to talk about the special procedures. Now, we've taken a history, we've got a lot of information. The history is sometimes the most important. You've listened to the patient. You've done a very careful pelvic exam. Then what kind of special tests…?

Dr. Dell: Very often a patient will require what we call urodynamic testing. This is just a big term for several things that we do to really take a specialized look at the bladder and pelvic floor. Very often this involves placing a few catheters, one in the bladder, one in the vagina. We'll fill the patient's bladder up with water while we're asking her to tell us what she's feeling and taking certain sensations. We take careful measurements. We even very often look in the bladder with a little scope. The patient can watch right on the screen with us while we're doing that and we can show to her what's going on. But that testing gives us really a whole lot of information about what's going on from the function side of things to correlate with the anatomy that we got in the exam.

Dr. Bob: Now, when you find out exactly what's wrong, let's talk about the specific treatments that you have. Let's talk about. for instance, pessaries.

Dr. Dell: Pessaries are just wonderful devices for the right patient. This is just one type of pessary. It's called an incontinence ring. You can see it's made out of a surgical grade rubber and it's flexible and this is one of the most easy to use for patients who have that activity related leakage-runners with problems with leakage during aerobics or tennis or golf-people who aren't sure that they want to undergo surgery but are tired of having to wear pads and change clothes for that kind of thing. Very often we can fit the patient with something like this. When it's fit properly it's so comfortable the patient can't tell that it's in there and yet can do all her activities and remain entirely dry. So, that is probably one of the best nonsurgical options available for the right candidate.

Dr. Bob: Now, this is inserted inside the vagina, pushed up against the urethra?

Dr. Dell: That's right. This area right here provides that extra support underneath the bladder neck which is really the critical component for stress incontinence.

Dr. Bob: And, any other type of pessaries?

Dr. Dell: They're at least 15-16 different types of pessaries and every one of them comes in many different sizes so it really needs to be tailored to fit to the needs of the patient and the anatomy of the patient.

Dr. Bob: Pretty easy to find the pessary that you know will work for the patient?

Dr. Dell: After you do a few hundred of them, it gets easier.

Dr. Bob: Let's talk about surgical procedures that we use. Sometimes if people have just got a stretched pelvis, you need to do surgery. How good is that surgery ,and what do you do now?

Dr. Dell: Well, over the last few decades at least a hundred different procedures have been used for these kinds of problems. Unfortunately, many of these did not hold up in terms of good, long-term success rates. So much has happened in just the last five to seven years in terms of advancement of the surgical techniques for it to be an easier process for the patient to go through and a much better long-term success rate. And so, one of the categories of procedures that we do so many of is a category called a sling. A sling is simply a hammock of material that we place underneath that bladder neck, primarily for people who have stress incontinence. What's so exciting is that some of the newer material, this is one of the newer synthetic materials, you can see, it's a very thin, pliable material. This is called the TVT, it stands for tension free vaginal tape, type sling procedure that is very, very easy to insert for the patient. In fact, we do this in the operating room but without putting the patient to sleep. So, she talks to us throughout the procedure and we're able to put that underneath the bladder neck and even fill her bladder up with fluid and have her cough and do every maneuver so we're satisfied that we have things right where we want them. She's awake the entire time and can often go home the same day or the very next morning and it has very good long-term success rates, at least 85-90% lasting beyond five years.

Dr. Bob: Now, not being a surgeon, I always thought a pelvic sling was a rather large sling that lifted up the whole pelvis. This is a very small apparatus. And you do this while the patient is awake?

Dr. Dell: We do that with the patient awake and is able to talk and communicate to us in the operating room throughout the procedure.

Dr. Bob: How do the patients like it?

Dr. Dell: They seem to really like it. The ability to recover so much more quickly compared to more traditional surgical procedures that we had, of course, is very popular. The patient will very often be able to empty her bladder on her own without a catheter from this kind of sling within 48 hours or less. Whereas it was typically more like five to seven days or longer for a more traditional type sling. So, this has got more like a two week recovery period rather than a standard six week recovery from a larger pelvic surgery that we've been used to.

Dr. Bob: In general, what type of person that's listening to this show would be the candidate for this surgical sling and how do you talk people into coming and seeing the doctor if they've got urinary incontinence? It's just embarrassing or they don't really need to get it fixed or….

Dr. Dell: If people understood how incredible common it was and those who really feel like they're suffering with this in silence, probably have 50% of their friends who have the exact same problem and they haven't talked about it. The biggest key is to seek help. If it has any interference in your quality of life, if you're not resting well, if you're avoiding activities because of a leakage, if it's embarrassing or hard to go shopping or enjoy time out with friends because you're constantly running to the bathroom, those are the reasons to seek help. There's tremendous help available. There are many different things that we have available today that just a couple of years ago were not even options. If an individualized approach is set up and time is taken to work with the patient, most patients, not all, but an overwhelming majority of patients can get a dramatically improved quality of life and be able to exercise and enjoy their life so much more.

Dr. Bob: It must be a great thing to be able to provide that service for somebody.

Dr. Dell: It's a privilege.

Dr. Bob: Now, let's talk about one other thing - urge incontinence. That's where somebody just has the desire-they've got to go and they've got to go quick and may not be able to make it. Are there medications?

Dr. Dell: There are tremendous medications available. Again, the primary medications we use for this were not even available five years ago. We have tremendous success rates on taking somebody who might be going 20 or 25 times a day, may be getting up five or six times at night and can't get rest, back to a normal voiding pattern which would be five or six times during the day and zero or one time at night.

Dr. Bob: And one of those medicines would be?

Dr. Dell: Detrol and Ditropan XL are the primary medications we use for that. One other thing, overactive bladder symptoms - urgency, frequency, urge incontinence -- are extremely common. Pelvic pain disorders in women are very common as well. There is endometriosis and many other things that are talked about when pelvic pain and overactive bladder symptoms cross. Patients need to be evaluated for a bladder condition called interstitial cystitis because very often that can be the cause of both categories of problems and again, very often we can treat that with medication.

Dr. Bob: Jeffrey Dell, I want to thank you. You've been a great teacher. I love having you on The Dr. Bob Show.

Dr. Dell: Thank you. Thank you.

Dr. Bob: You are full of information and I think the bottom line is, if you've got urinary incontinence, don't be embarrassed about it. Get it fixed. It would be a very, very simple thing to do and may change the productivity of your life. Now, we're going to want you to stay tuned. We're going to be talking about diet or exercise. Which is best for you? You got that ringing in your ears? Taking to much steroids? If so, it could be causing you problems and if we've got time, we'll talk about iritis, inflammation in part of the eye.

Announcer: Up next on The Dr. Bob Show, fitness expert, Missy Kane, has some tips to help you achieve your personal best and later, Dr. Bob answers his mail.

Missy Kane: To prevent urinary incontinence, urologists like Dr. Dell will tell their patients it's best to be in good shape and to be at your ideal weight. If you're overweight, this can cause problems on the pelvic floor and lead to urinary incontinence. So, if you need to lose weight, you need to exercise at least four times a week for 30 minutes each session. Walking, jogging, swimming are great but there's one exercise that you need to do that's specific. It's called a cagle. Women hear about this when they're pregnant. To do a cagle, you simply act like you're trying to stop the flow of urine for a couple of seconds. Do this at least ten times a couple of times a day and if you have a specific problem like a prolapsed bladder, then you need to check with your doctor because jogging and hard exercise can make the condition worse. For the Dr. Bob Show, I'm Missy Kane.

Conclusion of Interview:

Dr. Bob: I want to thank Dr. Jeffrey Dell for his excellent discussion on female urinary incontinence. A lot of great information, great teacher, great facts.

Letters:

And now we have some questions that I've compiled from you, the viewing audience that I think you'll want to know that will be helpful to your health.

Letter #1: "Dr. Bob, which is the best for weight loss-exercise or dieting or both?"

Response #1: Well, let's look at some of the studies. There's no question that if you want to lose a lot of weight, the best way to do it is by dieting. And you can diet and lose over a year or even six months 15, 20, even 30 pounds of weight but what statistics show is when people just diet, low and behold, four or five months after their diet is through, they've gained all that weight back! Statistically, the study that we were looking at showed people gained back an extra five pounds after the diet. Now, the best news was is those that dieted and exercised on a regular basis, they lost six pounds, averaged a half or a pound a month and those people kept their weight off when they kept exercising. And we say on The Dr. Bob Show exercise is one of the most important things you can do. Maybe the best exercise for you would be walking. Studies show that walking will improve heart disease. It decreases the incidence of strokes, can prevent Type II diabetes, helps with osteoporosis and even can help with depression. And so, make exercise part of your life. You'll be happier and have less stress and lower blood pressure and you'll lose some of those pounds.

Letter #2: "Dr. Bob, why do people get ringing in the ears?"

Response #2: Well, we call ringing in the ears tin-ni-tus or tinnitus. Both are proper pronunciations and it's a ringing in the ear or a roaring in the ear. It's almost like listening to a seashell or a high pitched wind that you hear all the time. Most people have gotten some ringing in their ears at sometimes, some tinnitus. Like, if you've gone to a concert and the music was real loud and you walked out and your ear was just ringing. Or sometimes just in a quiet room at one time there will be ringing in your ears for a short period of time. Now, there are millions of people that have tinnitus that's so bad that it interferes with their lifestyle because they can't go to sleep. They can't concentrate or allow themselves to go to sleep because of the ringing in the ears. We're not sure what causes ringing in the ears in all people but it's thought to be in part of the inner ear some of the hair like follicles that help assimilate sound, some of those may be ruptured leaving a ringing in your ears. Certainly if you've got prolonged ringing in your ears, this is something you need to see your doctor about and see if there is something he can do to help that tinnitus.

Letter #3: "Dr. Bob, what are the side effects of steroids? My next door neighbor has arthritis and is taking steroids. What are some of the harmful side effects?"

Response #3: Well, there's a whole bunch. If we take steroids for too long a period of time, it can cause cataracts in the back of the eyes. We call them posterior subcapsular cataracts. It takes the elasticity out of the skin where we bruise very easily. It takes the calcium out of the bones where we get osteoporosis and you can get broken bones very easy. It increases the incidence of ulcers and even GI bleeding. It elevates the blood sugar, holds on to fluid, moon facies, acneiform rash, can take the blood supply away from the hip and can even cause pancreatitis in some people. It can be a very dangerous medicine if overused but sometimes we have to be on steroids in order to function. Be sure that you regularly discuss with your doctor the side effects of steroids if you have to take steroids.

Dr. Bob: And we've got about 30 seconds. One more question.

Letter #4:"Dr. Bob, what is iritis?"

Response #4: Well, that's a long discussion but it's an inflammation in the part of the eye where we've got red eyes, light bothers the eye, there is pain in the eyes, redness around the color of the eye and it is treatable with steroid drops.

Closing

Dr. Bob: And that's all the time we have. Be sure that you're getting your exercise. Get eight hours of sleep, start that day off with a good breakfast of fruit and fiber and have laughter in your life.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com