The Ins-and-Outs of OAB

When is that sudden urge to go so bad that you should seek out medical help? How can I tell the difference between a UTI and OAB? How much water should I be drinking every day? Can a woman actually visit a urologist? 

These are some of the important questions that we address with today's guest, Dr. Raveen Syan. She's an associate professor of clinical urology at the University of Miami's Miller School of Medicine and a specialist in a number of women's pelvic health issues, including the treatment of stress urinary incontinence, pelvic organ prolapse and overactive bladder. 

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Music:
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

If you look at the numbers behind incontinence in women, it’s hard to believe just how big an issue it is. Incontinence affects more women than diabetes, breast cancer and heart disease, but it doesn’t get the attention it deserves. That’s why NAFC has created the We Count campaign, to help you realize that you are not alone, and there are treatments available right now that can make a real difference in your life. Visit NAFC.org/we-count to learn more. 

Transcript

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we'll get them corrected immediately. 

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers. All available at nafc.org. 

Welcome back to another episode of Life Without Leaks. I'm your host, Bruce Kassover, and joining us today is Dr. Raveen Syan. She's an associate professor of clinical urology at the University of Miami Miller School of Medicine. She's done a ton of research. She has a particular interest in things like stress urinary incontinence and pelvic organ prolapse and overactive bladder. And really interestingly, she's been doing a lot of work focusing on the issues that minority women face when they seek out healthcare. So thank you for joining us today. 

Dr. Syan: Thank you for having me. 

Bruce Kassover: So tell us a little bit about your own journey to join us today. How did you get to be here as an associate professor of clinical urology?

Dr. Syan: Well, in med school, you kind of make a decision pretty early on if you're interested in becoming a surgeon or managing patients on a more medical, less interventional pathway. And I loved surgery. I love being in the operating room. I love providing patients with near instantaneous relief from whatever problems they're dealing with. 

Urology specifically is, is a fantastic field. It is super diverse. It's always up on the latest technology. We treat men, women, children, all ages, and there's actually a diverse range of disorders that we treat. Specifically. I found myself in the world of urogynecology within urology because I really liked providing care to women, which I think as a female provider is something patients are really seeking. I also really enjoy the complexity of benign care where it's not a single surgery for a single problem, but it's really tailored and individualized to the person and what the person's knee needs and challenges are. And it's a great field. It's a, it's been a wonderful journey, and I really love teaching and doing research, so that's how I've been part of the University of Miami. 

Bruce Kassover: That's great. I love hearing that. So it's always nice to hear somebody who has real passion for doing what they're doing. And I suppose, do you find that a lot of people tend to be surprised when you say that you are a urologist as a woman? Is it something that there's still a lot of sense in that it's a male field particularly? 

Dr. Syan: Yes, there's definitely still a sense that it's only males who are urologists, and another big misconception is that only males go to urologists. So women are affected by nearly every condition, including issues with the kidneys, the bladder, the pelvic floor.

Yes. We don't have some of the other organs that men have that urologists do specialize in, but we do have specifically the bladder, especially where women deal with a lot of problems there and urologists are the best people to be able to address that. 

Bruce Kassover: That's interesting. So how does a woman, if, let me put it this way, if you're a woman who doesn't even realize that the field of urology is something that is relevant to you, how does somebody wind up getting in front of you then?

Dr. Syan: Well, hopefully people are understanding that when they see the term ‘urogynecologist,’ if they see ‘urologist’ following, that still means that we are the appropriate people to see. I think also, unfortunately, women do rely upon referrals from their, you know, primary physicians, the primary physicians who understand where to send patients for some of these issues.

So, I'll admit, it's not the most easy route for the female of their own accord to know, to come to a urologist, but hopefully by, you know, seeking care for a specific issue, you'll find us as your gynecologist, or you can rely upon your primary care to help guide you in the right direction.

Bruce Kassover: That makes a lot of sense. And of course, you know, going to your primary care first is what most people do. So I would imagine that that is a good and straightforward pathway to you. 

So I'm really interested in hearing a little bit about your take on overactive bladder, because I know that when it comes to the whole family of urologic conditions, there's a lot of confusion among patients about what they even have because, first of all, they may just not know what all the different conditions are, and when they have certain symptoms, they may be sort of confused about, you know, could it be this, could it be that? So can you tell us a little bit about overactive bladder, about OAB and what people should be looking for and what they could expect that they might be facing before they need to seek help?

Dr. Syan: So overactive bladder is a condition based on symptoms, so it's going often to the bathroom. It's having urgency. So when you have to get to the bathroom, you're like racing or you have trouble waiting in a line and it includes leakage. Sometimes that urgency is so severe that, you know, your bladder spasms so strongly that you actually leak.

In terms of things to look out for is when these symptoms start to bother you. There's many women who drink lots of water, and so, therefore, they go to the bathroom a lot. They're used to it. It doesn't bother their lifestyle. You don't need to seek care for that. But if you're noticing, even when you're restricting fluids or even with high fluids, you need it and you're going often and it's becoming problematic, that's when you should seek care.

Bruce Kassover: Oh, that's really interesting. So even if you're restricting fluids, if you are noticing that you're having those symptoms of urgency, that's a red flag. Okay. That's very good to know. But leakage itself is not a necessary symptom for OAB. I mean, it may happen, but it doesn't have to happen. Is that that correct?

Dr. Syan: Absolutely. So people can have overactive bladder without leakage, so that includes the symptoms of urgency alone – but you make it, you don't actually leak – or going very often. And it should be noted that not all leakage is overactive bladder. So that is some of the complexity that is related to the pelvic floor. But there are different types of leakage. When we're speaking about the leakage related to the overactive bladder, it's specifically leakage with the urge to urinate, so it's called urge incontinence. 

Bruce Kassover: Okay, that makes a lot of sense. Now, how common is this? I mean, is this something that is frequent enough that people, if they start having these symptoms, they should be like, you know, “Oh yeah, this is really something that I should be investigating,” or is it a little less common than that? 

Dr. Syan: In the general population, all ages grouped, it's about 12% of women. That percentage really changes with age though. So, you know, when you're young, it's really not very common. But as we get older, and certainly as we start to approach our sixties and older, we're looking at a much higher prevalence. And some studies cited as high as 40% approaching, nearly half of women experience at least some of these symptoms to some degree.

Bruce Kassover: Wow. That is a crazy number. I mean, even 12%. I mean, if you look at… of the entire population, that is a massive, massive number. But now you said that it becomes more common… I hear people talk about the difference between what's common and what's normal. Can you talk a little bit about that also?

Dr. Syan: The way I like to talk to patients about these symptoms, because you know, very often women are like, well, it's part of normal aging. My grandmother, my aunts and cousins, they all experience this. This is just being a woman and getting older. So there is truth in that statement. It is a natural process that very often happens to the bladder as we age. However, that doesn't mean that you can't address it. I mean, that's the great benefit of living in this modern era. We have ways to help patients. They don't just have to live with their symptoms and their bother. 

Bruce Kassover: Yeah, that reminds me of, I remember somebody was saying that, you know, it's sort of like heart attacks. As you get older, they become common, but that doesn't make them normal. 

Dr. Syan: Exactly. 

Bruce Kassover: That is, that is a very sensible way. So I like that. So you're having these symptoms. One of the things that I think is a real barrier is that people don't want to talk about it. They're embarrassed by it. They feel, you know, it makes them feel, maybe, infantilized in some way, you know, because it's like you're losing that, that sort of control.

What do you say to somebody who is really hesitant to go because they just have too much anxiety about it?

Dr. Syan: That's tough. I mean, it, I think the ways that I would encourage people to try and overcome that is to recognize it's very common. So when you come to see someone to talk about it, trust me, if you're in my office, I've spoken to 30 other people that day about this issue.

So, hopefully that helps relieve some of the anxiety. B, finding a provider that you feel comfortable with, someone you can relate to. I do think for women that often is a female provider, and so you can seek a urogynecologist’s care, and that could be a gynecologist or a urologist. But finding that person where you feel open to that conversation.

And then see, there's many great resources online, this podcast included, but others such as the American Urogynecologic Society that has some of these patient handouts to help you learn the terminology. And so maybe by speaking about it in a way where you're using the terms like, “I have to go frequently or urgently,” maybe that can help people kind of overcome some of that embarrassment.

Bruce Kassover: It makes a lot of sense, and I certainly hope they take you to heart. I remember I was taking a peek before we, before we started speaking today at one of your recent papers where you were talking about, if I read it correctly, because I'm not always good at reading medical papers, but if I read it correctly that you find that people are more comfortable speaking with a healthcare professional who resembles them in some way in terms of either gender or age or race or or language. I mean, is that fair to say? Did I read it correctly? 

Dr. Syan: Absolutely. So there's a lot of studies that show, generally, females like to see female providers. They just feel more comfortable, and especially when we're speaking about sensitive terms, things related to the pelvic floor. So urine, sex, pain. Women very often find it difficult to speak to male providers about this. So, you know, there's a real importance in what we call ‘gender congruence.’ So, people identifying themselves with their provider to feel like they have the freedom to speak with them in a comfortable way and language is a huge, huge part.

And so, you know, with our very diverse country, it's important that you find somebody who can speak with you either directly in your language if English is not your first language or through the use of interpreter or translator. 

Bruce Kassover: I'm wondering, once you finally get in front of the physician, you've had the courage to bring up some of your symptoms, your concerns, your questions, what is the diagnostic process like?

Dr. Syan: So when it comes to overactive bladder, it's actually a very straightforward visit with a clinician. It's just a ton of questions trying to quantify how often you're going. So how bad is the frequency, how bad is the urgency, how often you leak, if that's present, and most importantly, what is the degree of bother?

Bother is really what dictates what treatments we pursue. There are a couple things that, especially urologists like to just check – safety checks – before we give you that diagnosis. One is just check your urine. Make sure we're not actually dealing with an infection, because absolutely bladder infections can lead to these symptoms.

And the second thing is just making sure you empty your bladder, and that's very easy. It's just a quick ultrasound check of the bladder in the clinic, takes a minute. Other than that, it's, as I mentioned, it's a diagnosis of symptoms. 

Bruce Kassover: You know, I really, first of all, I love hearing the fact that it's not terribly, not terribly invasive. You're not going through all sorts of, you know, crazy tests or anything. That's very nice. But you mentioned something, you know, one of the things we get an absolute ton of hits on, on the NAFC.org website is anything to do with UTIs. People are really, really concerned and always looking. Maybe it's because it's terribly common as well. But you mentioned how you want to check to make sure that it's not an infection. Are some of these symptoms associated? Can some of these symptoms be associated with UTIs? And if so, you know, aside from going to the doctor, is there anything you can do to sort of help figure out what's going on or the difference between the two?

Dr. Syan: So absolutely these symptoms coincide with symptoms. When you're having an infection, it's going often urgently. There are usually other symptoms, not a hundred percent, but other symptoms that accompany infection is pain with urination, bladder discomfort, sometimes blood in the urine, and extreme cases it can be things like fevers, chills, you know, just feeling unwell. 

Ways that you can distinguish the two is, it should be a sudden worsening from baseline. So, whatever urinary health you have, if all of a sudden it starts to get worse and you don't have the blood and the pain, the things that are the clear hallmarks, but it's suddenly gotten worse, the first thing you should check is it's not a UTI, because you really can have that without those big obvious symptoms.

Bruce Kassover: So now we're in the doctor's office. We've done some of this. We've gone through the diagnostic process. What are some of the treatments that I might have presented to me, or what are some of the treatments that a woman might have presented to her to address OAB and its symptoms? 

Dr. Syan: So when it comes to overactive bladder, we do talk about levels of intervention. So, we start first with conservative interventions. That means lifestyle changes. So, trying to modify the things that irritate the bladder. So, try and avoid excessive caffeine. Switch to decaf or get it as close to zero as you can. Avoid carbonated beverages. Even sparkling water. Things like spicy food actually can be irritating to the bladder, and of course, alcohol.

Another thing that does impact bladder health, which a lot of people don't know is bowel health. So when you're somebody who has a lot of constipation, that can actually be really irritated to the bladder as well. So, getting good control of constipation, making sure you're taking things like fiber supplementation or stool softeners to help you to get to the goal of a daily soft bowel movement, which is good for the gut and good for the bladder.

Then we move on to the next step, which is medications by mouth. Now there's lots of medications. Everybody has an individual response to which one works best for them. There's no proof that one's better than another. There are side effects with a lot of them. Fortunately, there are two more that have no side effects.

You just have to find the clinician who can help you work with your insurance to get access to those medications that have no symptoms. Otherwise, it can be really cost prohibitive. And then there's the option of interventions. So, it's for the people who the symptoms are severe enough, they want to do something, they either find that the medications are not working or they already take too many medications. They don't want to keep taking medications, which is super common. 70% of people who have good control of their bladder symptoms with pills, they stop taking it either from side effects or again, they just get fatigued from taking these pills. So there are three interventions that we can do.

Starting from most effective, but most invasive to least invasive, but less effective. We start with the nerve stimulator. So the sacral nerve stimulator is like a pacemaker for the heart, but for the bladder. Basically it's composed of a wire attached to a battery that sits under your skin way down low at the level of the tailbone.

You can fly, swim, get MRIs, there's no restrictions with these new models. And it's just a simple procedure in the operating room to place the wire and the battery in one go, and it's working when you wake up. It's 90% effective. We don't just put the implant in. You always get a trial. So actually these trials can be done in clinic.

It's a simple procedure where we just place a tiny wire at the level of the deep skin. It sticks out of your skin for four days. You walk around, you live your life. We measure how you're improving or not, and then we remove it out. Remove the wire, good or bad, and we see how you did. And if you like the results for yourself, you decide if you want to move forward with the intervention.

That's a good option for like sort of a one-and-done intervention. It's just obviously, you know, more invasive. It's getting to the operating room, so there are others. Another really good option is Botox of the bladder, which is also 90% effective. Just like we Botox the muscles of our face to relax facial muscles, we can do that to the bladder so that it's less spastic and that's wonderful because we can do it in the clinic.

You don't have to go to the operating room at all. We just look in with a camera and especially in women. Looking inside the bladder with a camera is very easy. We just have these short little urethras, so it's painless. Uh, we look around and we just inject the Botox all over the bladder. The only challenge with Botox is it does wear off, so depending on how fast your body digests Botox, you need to get repeat injections every three to six months. Very rarely there can be trouble with urinating. It's very rare in women. 

And then finally there's a very non-invasive option. I kind of call it electrical acupuncture. At the level of our ankle, there is a nerve that connects all the way back up at the spinal cord to the nerve that goes to the bladder, the one that we target with the first one, the invasive one.

And what we do in the clinic is we put a tiny acupuncture needle, so no bleeding, and we just do a little buzzing therapy, electrical therapy to that nerve 30 minutes once a week for 12 weeks, and it's 70% effective. So completely non-invasive. There is a burden of visits to the clinic, but it's 70% effective, so it's a great option for people who are trying to avoid anything more invasive. 

Bruce Kassover: That's very cool. Now, how do you help the patient decide which treatment path makes the most sense for them? 

Dr. Syan: Well, I try and break it down for the patient in a way to help me understand what their goals are. So let's assume we're moving past the pills and we're talking about one of these three interventions.

People may find the idea of an implant, “Oh, there's no way. I don't want to put something foreign in my body,” so we know that's off the table. Some people are looking for something non-invasive because they have medical conditions. So the, what I call electrical acupuncture is a good option. Young, healthy people who really have the rest of their lives to unfortunately have to deal with this issue, the implant's a great option because it's, you know, sort of a one-and-done. It comes with the remotes. You can adjust it as you get older. Bluetooth technology only, and the batteries last 10 to 20 years. So it really depends on, you know, what the patient's goals and priorities are, and I just ask them, and I try and help them find the one that suits them.

Bruce Kassover: It seems like there are a lot of different mechanisms of action or the way that some of these things work. Is it fair to say that some of these are really focused on addressing the symptoms and others are more focused on addressing the root cause? What is actually going on in the body that causes OAB in the first place?

Dr. Syan: We don't entirely understand what causes overactive bladder. We have an understanding that there is excessive, inappropriate sensations being transmitted back to the brain of feeling full when you know there's really not that much urine there, and so then your bladder starts contracting. We know that there are some profiles of some different cellular changes at the level of bladder; it's really not well understood. 

We know there's at least a component of aging that contributes to development of overactive bladder. Things that affect the brain can also really impact the bladder. You know, the easiest one I find to explain is stroke. So, when you have a stroke, that means a loss of areas of the brain that are, you know, working the way they used to. And I explain it sort of like, you know, when you were, before you were a toddler, you just, whenever you were full, the bladder just spasmed. As you got potty trained, your brain learned how to inhibit those signals and control and decide when you start to urinate.

And so some of those pathways that you developed can be impacted. So things in the brain can certainly impact it. It's actually very common in people with MS, which is an autoimmune disorder that affects the nerves, and actually a whole host of neurologic conditions affect the bladder. So we know that the pathway between the brain and the bladder in terms of the nervous system is really important, but exactly what causes it, I don't think I have an answer for you. 

Bruce Kassover: Fair enough, yeah, and I suppose we will continue to learn more as medical science continues. But speaking of medical science and talking about things, you know, related to the causes or the symptoms. I understand – and tell me if I’m mistaken – didn't the American Urological Association recently make some changes to their guidelines, either for physicians or patients about the care for OAB and, and if so, what were those changes and what's different now?

Dr. Syan: The biggest change is that you, we used to say, you first have to try conservative things, then you can try pills, then you can go on to procedures. We've really recognized that pills are a big problem for patients, and as I mentioned, 70% of patients either can't tolerate the pills or can't continue them for a host of reasons.

So what we got rid of is this, “You must follow this stepwise pattern.” We acknowledge that there are people who are living with this problem and they want a more significant intervention that's got a higher probability of success. So we can take patients straight to some of those procedures if that's their interest.

They don't have to try pills. Now, insurance is a little different. Insurances may make you try pills first. So we just, as clinicians, want to make it clear that we are not creating those restrictions. It's totally appropriate to be able to go straight to a procedure if that's, you know, what's your priority.

Bruce Kassover: Well, that's certainly encouraging. And I said I certainly hope that insurance, companies pay attention to what the medical professionals are actually saying, which… 

Dr. Syan: Well, that's unfortunately, yeah, unlikely. 

Bruce Kassover: I know. But that being said, so it sounds like we have a lot of really effective ways to treat and to care for patients who are dealing with these symptoms. What if I don't want to become one of those patients in the first place? I know you mentioned some lifestyle changes, things like avoiding caffeine and alcohol and spicy food. Are there other things that somebody who wants to try and maintain the best bladder health that they can beforehand do to ensure that, not to ensure, but to improve their chances?

Dr. Syan: Yeah, so some preventive things you can do is pay attention to your bladder. So, what I'm talking about here is, don't hold your bladder for too long. We really should be peeing about every four hours. So I know it's hard. A lot of people at work, it's hard to take that time, but really try and remember. Set a schedule for yourself where you're not waiting too long to go urinate.

Don't rush out to the bathroom. You know, let your bladder finish emptying. Get good control of constipation again, that is good for both bowel health and bladder health to have, you know, soft, regular bowel movements every day with complete emptying. And, you know, we talked about some of those irritants that you, you can avoid. You don't have to if you don't have the symptoms. But these are the sorts of things that you can do to prevent getting to that point. 

Bruce Kassover: Oh, very good. I like that. And, you know, I'm wondering, since we're talking about those sorts of things, do you have any guidance on how much water we should be drinking a day? And I ask that because I was just recently reading something that mentioned how in Europe many care providers recommend a different amount than you often hear recommended here in the States. And I'm wondering is there’s any sort of general consensus and what makes sense? 

Dr. Syan: So back in, probably, the nineties, we as a medical field kind of misled the public because we thought it was correct that drinking lots and lots and lots of water was really important.

Uh, it turns out it's not true. It doesn't confer any health benefit to drink a gallon of water a day at all. So when you ask the nephrologist, the kidney doctor, what you should do, they'll say, “Listen to your thirst.” Your brain has an amazing capacity and an amazing mechanism to tell you when you need water and when you need to drink.

So the first thing is, obey the thirst signals. Secondly, it's hard to quantify exactly how much you need. It really depends on your body size, your level of activity, the heat in where you live. So, you know, I'm based out of Miami, so I'm going to need a lot more water than somebody say in, you know, Greenland or something like that.

So it does really depend on how active you are, what your environment looks like. Generally speaking, we really discourage, you know there's these popular bottles out there where it's like, finish a gallon of water or three liters of water a day. That's excessive. There's very few people who actually need that much.

Now you're working outdoors all day. Maybe that's a different story, but the primary thing is, listen to thirst. Generally speaking, when patients are needing guidance, I say, in a place like Miami where you're outdoors and you're not exercising excessively, I would say a liter to a liter and a half probably erring towards a liter and a half is the right amount. But again, the ultimate determinant is your level of thirst. Your brain will tell you what you need. 

Bruce Kassover: But now you're using words like liters, and I can… if it ain't pints and gallons, I don't know what you're talking about. 

Dr. Syan: Sorry!

Bruce Kassover: No, that's good advice, and I definitely appreciate that. So you mentioned earlier about going to your primary care physician. That really is the best starting point, you think? 

Dr. Syan: It's definitely a starting point. If you are, you know, lucky enough to be in a region where there is, you know, a wealth of urologists and urogynecologists, don't feel like you have to go to your primary care first. However, the majority of America doesn't have easy access to specialists, so that doesn't mean that you can't get the care you need.

Your primary care physicians do know how to help you yo start the pathway of help or at least guide you in the right direction. So, you know, we talked about some of the challenges about speaking with providers, but I hope after this talk it's given you the confidence to talk to your physicians and just remember, they talk to patients all the time about this.

So at least with a physician, you should feel no embarrassment because this is what we do, this is what we take care of. So, you absolutely can to turn to your primary care physician first if need be. 

Bruce Kassover: Well, that's certainly encouraging, and I'm wondering, speaking of encouragement, as you know, this is Life without Leaks, and we always like to end by giving our listeners one little hint, tip, strategy, bit of advice about how to live a life without leaks. So I'm wondering if you might have one you could share with us now… 

Dr. Syan: So my advice for living a life without leaks is, don't choose to not take care of your issues because you think it's normal. It is natural. It does happen with age, but that doesn't mean you have to live with these symptoms. We are blessed to have lots of options available to help ourselves with these problems.

So you don't have to live like this just because you think it's natural and it comes with age. There is a way to help you and the most important thing is we want to improve your quality of life, and there are great quality of life options out there. 

Bruce Kassover: That's outstanding and I hope that people take what you have to say to heart. And so I want to thank you for joining us today. We really appreciate it, and we certainly hope that our listeners got as much out of it as we did. 

Dr. Syan: Thank you so much for the invitation.

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin McLeod. More information about NAFC is available online at nafc.org.