Beyond Pads and Panty Liners: Real Solutions for Women Who Leak

Millions of women experience overactive bladder or urge urinary incontinence, but far too many assume it's simply part of getting older or something they have to live with. The truth is, effective treatments exist, and help may be easier to find than you think.

In this episode of Life Without Leaks, we welcome urogynecologist Dr. Susan Oakley to follow up on her recent NAFC webinar and answer listeners' most pressing questions. It's an honest, practical conversation about overactive bladder, urge urinary incontinence, and the latest treatment options. Dr. Oakley explains the difference between common bladder conditions, discusses everything from pelvic floor physical therapy and medications to neuromodulation and Botox, and shares why so many people wait years before seeking care.

Dr. Oakley also addresses common misconceptions about Kegel exercises, vaginal estrogen, prolapse, insurance coverage, and emerging therapies. Most importantly, she reminds listeners that bladder leaks are not something anyone should simply accept, and that seeking treatment early can dramatically improve quality of life.

Listen to Dr. Oakley's full webinar here.

Find out more about Dr. Oakley by clicking here and click here for her podcast or search for "The Lady Bod" podcast on your favorite player.

For more information about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram and Pinterest.

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

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: If you've ever planned your day around figuring out where the nearest bathroom is, worn a pad just in case, or wondered whether bladder leaks are simply a part of getting older, this conversation could change the way you think about your health forever. We're joined by Dr. Susan Oakley, who's following up on her recent NAFC webinar to help demystify leaks and answer some of the most common questions women have about bladder conditions.

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, as always, is Sarah Jenkins, the executive director for the National Association for Continence. Welcome, Sarah. 

Sarah Jenkins: Thanks, Bruce. 

Bruce Kassover: Yeah, I'm excited because today we're gonna be talking with Dr. Susan Oakley. She is a board-certified urogynecologist with fellowship training in female pelvic medicine and reconstructive surgery, and she specializes in, complex pelvic floor disorders, including things like incontinence and prolapse and overactive bladder and pelvic pain.

She's joining us today because she has just recently done a webinar with the National Association for Continence. It was sponsored by Medtronic. It was called From Symptoms to Solutions: Navigating Overactive Bladder and Urge Urinary Incontinence. She's gonna be talking with us today a little bit about that webinar, about what was discussed, and also take a moment to answer some of the questions that the people who attended had left with us. So Dr. Oakley, thank you for joining us today.

Dr. Oakley: Thank you , Bruce, for having me. Thank you, Sarah. I am very excited to be here. 

Bruce Kassover: I am too. And really, before we even get into it, I'm wondering, could you tell us a little bit about how you got to be here, how you got to be giving us a webinar? What is your journey to becoming the doctor that you are today?

Dr. Oakley: Oh, great question, Bruce, but it's a very long answer. I'm Southern and theatrical, so I love to paint a story with words. But essentially, I am the daughter of an Army surgeon, and as a young child bounced around, but don't remember it. I grew up in North Carolina. I'm a proud Tar Heel, and ended up going to the University of North Carolina at Chapel Hill in hopes of maybe containing something in the arts, either being a novelist or being on stage, and I had every intention of pursuing more of an actress type of career.

I moved to New York City. I ended up working for MTV, and none of this sounds related to what we're talking about today. But amidst all of this, that sort of career did not pan out, and I did some mission work in Africa with my father. I- this was during his private practice time outside of the Army, and it was just such a nudge and just one of those moments for me where I knew that I needed to change gears and instead pursue a career in medicine.

I also knew that I just needed to help women. Specifically, my niche or specialty is treating females with incontinence and pelvic floor issues. So not to disregard any men who tune into the podcast or are part of the NAFC, but I definitely saw that commitment when I was in Africa of the moms who were standing in line after walking miles and miles all night long with their young infants and toddlers to receive much needed vaccinations.

And seeing their commitment for their children, I knew I wanted to commit myself for the rest of my life to caring for those women because those women are caring for so many other people. And without implying any gender bias, I just really love the idea of taking care of women. I feel they are the household managers, and oftentimes do take care of everyone else in their lives at the risk of not advocating for their own healthcare.

And seeing what the NAFC does and this podcast, taking away the stigma of incontinence and pelvic floor issues and bringing to light education and empowerment, it's just something I want to be a part of, and that's really how I got to this moment. 

Bruce Kassover: An amazing story. And first of all, where in Africa were you?

Dr. Oakley: That time, I was actually in Malawi, so near South Africa. Since then, I've worked in Kenya several times and lived in Ethiopia for six months doing pelvic floor fistula repair work. I also spent some time in Honduras offering surgical treatment options for pelvic floor disorders. And then ultimately, I spent four years in the southern part of Israel, in the deserts near Be'er Sheva really completing my medical training.

Bruce Kassover: That's unbelievable. I'm jealous about how well-traveled you are. That's fascinating. I'm wondering, first of all, how does that inform the care that you provide to your patients right here in the States then? 

Dr. Oakley: I'd like to think that having traveled and just being part of other cultures and languages and religions, and really immersing myself in each of these places, has allowed me to be more resilient, and also cognizant of what a variety of treatment modalities in the realm of healthcare can bring a patient.

So there's really nothing that I am against. I think I, I have lots of women say, "What if I try this? What if I try that?" And I think we got a lot of questions during the webinar that may not be based in evidence-based medicine or research, but certainly something that we should discuss. And again, I really genuinely feel having traveled and picked up things from other countries and cultures has allowed me to be okay with that element of what might work for a particular patient's journey and their treatment for these pelvic floor issues.

Bruce Kassover: That sort of openness I'm sure has to be really welcomed by your patients. Because they're clearly, I would imagine in most cases, nervous, apprehensive, uncertain about what's gonna happen. So I'm sure that really goes over well with them.

But I understand that in terms of outreach and communications, it's not just you in the office. You also do a podcast. Isn't that, is that correct? 

Dr. Oakley: Yes, I do, and I'm so grateful for the five people who listen to it. I've been doing it for six years, and I love that opportunity, and that's where I put all the theatrical part of my life that didn't work out when I was 22, I put it into the podcast. 

Bruce Kassover: With the world of podcasting today, there are so many podcasts out there. It's very hard to break through. But the good thing about a podcast like yours and like ours is that we have an audience that searches for us. It's not just like scrolling, saying, "Oh, what's entertaining? What's true crime?" It's, "I have a problem. I'm finding people who have solutions." I'm sure that there's a few more than five people out there for you. 

Dr. Oakley: Just a few. But it's just like this one, right? This podcast that you do so generously through the NAFC. It's just about bringing education and awareness to a certain discreet problem that affects so many men and women.

Bruce Kassover: That's a perfect segue to talk about certain discreet problems. You participated in an NAFC webinar talking about things like urge urinary incontinence, overactive bladder, all that sort of stuff. Maybe you can tell us a little bit about urge incontinence and overactive bladder. Are they the same? What... Are they different? If so, how are they different? 

Dr. Oakley: They're extremely similar. Both have a component of a strong, sudden urgency to go urinate, right? I always say it's the feeling that you're about to wet your pants when you get to the front door of your house, and you just can't get the keys out of the purse quick enough or out of the pocket quick enough.

And since they both have that sudden urgency, they both are really overactive bladder at the most basic description. Urge incontinence is when the urgency to pee that immediately and that quickly is accompanied by actual leakage of urine, right? So it's not just the feeling you're about to wet your pants, you do wet your pants.

It doesn't have to be all the time, right? And I think that's the problem with these diagnoses, for me, women tend to overlook that initial urgency or overactive bladder and wait until it becomes incontinence, and wait till they experience that leakage with the sudden urgency to void before they seek treatment. So two separate diagnoses, but extremely similar. 

Bruce Kassover: You just said something that has me thinking, because, we often talk about how women are uncomfortable... not just women, people who are experiencing these symptoms are often uncomfortable talking about it. It's been stigmatized and, there's a sense of embarrassment, and they just don't like to mention it.

However, we're entering a bit of a weird time or a different time nowadays where it's very common, for example, to see commercials on TV where women will be talking about these issues, and we love it. It's great. You should be talking about it. You should be open to discussing it. But I'm also wondering now, for those people who are just beginning to experience these symptoms, is it possible that some of this normalization is actually making it seem a little too normal, in the sense that, "Oh, you know what? Everybody goes through this. I'm not gonna worry about dealing with it. It's just, eh, everybody gets leaks. You can see it's all over the place. They're talking about it everywhere"? I'm wondering, should people take these things seriously early on when maybe they would normally discount them?

Dr. Oakley: Bruce, you bring up an excellent point, and I'm so glad that you did. I think the ability to normalize certain abnormal healthcare issues is really a characteristic of the female population. All jokes aside, right? But we do have a tendency to say, "Oh, that's because we're women. Oh, that's because we're aging. Oh, that's because we've had kids."

I think by and large, for years, we women have normalized abnormal healthcare symptoms and signs of disease, sadly, right? So I'm not sure that the media attention being brought to things like incontinence has further permitted that. I think it's in our nature. Unfortunately , Your question has maybe a second answer to it from my point of view in that I think the media attention and the marketing from big companies, like maybe Procter & Gamble, for example, has said, "It's okay to wear diapers. It's okay to wear pads. It's okay to wet your pants, because we make something that will soak it up."

And while that is reasonable, Bruce, and there's certainly no reason to not purchase these items, what I'd like to see more is attention brought to the fact that true evidence-based medical treatments are simple with few, if any side effects, and reasonable to pursue for most men and women if they really don't want to leak.

I've had a patient say, "I don't leak. The diaper catches it." And so I... for me, that's what this sort of attention to the issue of incontinence has caused. Not so much, again, a normalization, but just saying it's okay to go halfway on treatment, and that scares me a little bit, Bruce, because I don't think anyone listening to this podcast would do the same thing should they be faced with a cancer diagnosis, right?

I don't think they'd say, "it's just stage one. I'll wait till my cancer gets to stage four, and then I'll do the treatment. Then it will be worth it." I really doubt anyone would say that, Bruce, but we have a tendency still to do that when it comes to incontinence. 

Sarah Jenkins: So knowing how much women put themselves last and they are taking care of everybody else in their family and they might be experiencing a leak here, a leak there, when would you suggest that they seek help? So many women, like you said, put it off and think that it's just normal until it builds and builds, and we've heard from a lot of urologists that say it finally takes some kind of breaking point where they've missed a really important event or something big has happened or they've had a big accident in public.

What are the early warning signs that may make a woman say, "Okay, maybe this isn't horrible yet, but it's something I should check out?" 

Dr. Oakley: Every woman should go ahead and seek treatment. If you honestly are waking up three times a night, if you cannot hold it for more than an hour during the day, or you get to that two-hour mark because you really pushed yourself and you think, "If I do not get this front door open, I am about to pee all over the kitchen floor," those should be the signs and signals that prompt you and encourage you to seek treatment.

I think, again, the analogy to cancer, no one would wait until it's stage four cancer to treat it. They would've gone early on, and we should do that with incontinence when you have the sudden urgency to urinate and can't sleep through the night and can't make it through the day. I just think there are other scary things, like the degradation of the skin from wetness against such delicate groin tissue, or just irritation from wearing panty liners and pads just in case.

Those should also be warning signs and signals that prompt and encourage women to seek treatment. I think, we've talked about this before, Sarah, and Bruce you might be aware of this, I think men and women have a tendency to delay treatment for a lot of medical issues because they think it's too scary or too invasive or has too many side effects or it's too much money.

And when it comes to incontinence, everything really is fairly cheap, easy, and, for the most part, covered by insurance with very low risk. So why not seek treatment sooner? 

Bruce Kassover: Agreed. It's funny. You talk about how women have a tendency to put everybody else first, and it's true. And then you also have men who are really good at avoiding any sort of issue and pretending that it's not really happening.

So between that, I think that you have nobody who wants to ever go to the doctor. That is really what it comes down to. 

Dr. Oakley: I know, Sadly. But I think we just, all jokes aside, have to initiate that conversation, and maybe that is the scary part. Maybe half the people listening to this are not necessarily afraid of cost or side effects.

It's just the anxiety of bringing the topic up in general. But I think if you're listening and you have a comfortable relationship with just even your primary care provider, whether that be a doctor, PA, or nurse practitioner, or maybe just your gynecologist is your primary care provider, then use the comfortability of that relationship to bring up this very sensitive topic and see where it goes.

Bruce Kassover: Yeah, I suspect that's really correct, that it's that first question, just getting it out. Once you can break the seal, then things become a lot easier, I'd imagine. 

Dr. Oakley: Oh, was that a joke? 

Bruce Kassover: Yes. I like it. That was a little bit. That was, but you know what? I'm bad with things like that.

So we were talking about how, aside from the absorbent products, there are a range of treatments that are available. Maybe you can give us an idea of what that spectrum of treatments actually looks like. 

Dr. Oakley: Great question. I think it really depends on the actual diagnosis. So if we're just focusing on overactive bladder and urge urinary incontinence, that is a completely different treatment algorithm than something like stress incontinence.

So very briefly, stress incontinence, weakness of the urethra tube or what I like to call the pee hole. And since it's a weakness in the pee hole, we have to figure out how to tone it up and strengthen it. So stress incontinence or leakage when you do stressful things like coughing, jumping, and sneezing is always gonna be best treated by surgery.

Surgery tightens the lazy, loose pee hole so that it doesn't just pop open when you do stressful things. But urgency incontinence is totally different. Urgency incontinence or overactive bladder, those are more related to a nerve spasticity and muscle spasticity. So our treatment should not tighten anything per se or lift anything per se.

Our treatment should be relaxing the nerve and the muscle so they're not firing so often, causing that sudden and strong urgency to urinate, right? And so the treatments are variable, Bruce. We could either have treatments to relax the nerve or treatments to relax the muscle. And I'm happy to talk about both. Do you want me to talk about the maybe muscle treatments first? 

Bruce Kassover: Absolutely, 100%. 

Dr. Oakley: Oh, let's go with that one. So the muscle we can relax anywhere in the human body with a couple of things, physical therapy and medicine, right? Those often relax muscle spasms, whether they're in your neck or your back or like a charley horse.

The bladder muscle is no different. We want to relax it with calming pelvic floor physical therapy, which is one of my go-tos. Absolutely love sending my patients there. Only takes a few visits. Medicine is another option to calm down that spastic muscle, and most of our pills are taken once a day, and they have very few side effects.

Some of the older ones may cause dry mouth, dry eye, and constipation. Some of the newer medications can bump up your blood pressure just a tad, but still safe to take if your hypertension is well controlled, right? So the pills, again, are ubiquitously covered by insurance for the most part, and if you were worried about side effects, you could always check with your insurance to see which one they are willing to cover.

The nerve treatments are a little bit more involved, Bruce. So is it all right if I spend a few minutes talking about those? 

Bruce Kassover: Oh, yeah, I'd love to hear it. 

Dr. Oakley: All right, great. I feel like there are three main nerve treatments to calm that nerve down so your bladder's not constantly spasming and pushing pee out.

The first nerve treatment is called PTNS, and that tibial nerve stimulation is a therapy that can simply be done in the office. So it's a 30-minute treatment once a week, usually with a nurse or staff member. Basically, she would gently and painlessly place a small acupuncture needle just behind your ankle bone, and it would send a stimulation signal to the nerve in your ankle, which actually goes all the way up your inner leg and thigh to your bladder. Crazy, huh?

I think that's pretty phenomenal and amazing. But that treatment is weekly, so a little cumbersome, especially for someone who might have an insurance copay every time they walk into a doctor's office. But it's minimally invasive, quick and easy, and you can sit there and read a book, knit a sweater, do a crossword puzzle, watch your show on your iPhone, whatever you want to do for that 30 minutes each week.

And again, that works great for overactive bladder and urge incontinence by calming the nerve to the bladder. The second and third option people consider to be a little bit more surgical, Bruce, and that would be the use of a neuromodulator or nerve implant. I always say these are like tiny pacemakers or just tiny batteries.

One can go in your tailbone just above your butt crack, and excuse my plain language. The other implant battery goes in that same spot under the skin behind your ankle that we were talking about. The ankle one was newly FDA approved back in September of 2025. And that sort of tibial nerve implant goes under the skin, so it lasts for about 15 years.

And even though it may look slightly bulky behind your ankle, it's certainly quick and painless and is done under 10 minutes in the office. And you can walk in and walk out and go back to work that same day. So I think that one's pretty great, Bruce.

The one in your tailbone does require that you test it externally for one week to just try it before you buy it, right? Make sure it works before you commit to it. It ultimately is a battery implanted in the top of the fat part of your butt cheek, and there's a small wire that runs under the skin from the implantable battery to the nerve in your tailbone. So basically, we can get to that nerve at its origin in your tailbone, or we can get to that nerve at the terminal end part in your ankle.

Those three nerve therapies are all quick, easy, low risk, and I think are great options, particularly for patients who may have reactions to medications. 

Bruce Kassover: What sort of success rate do they have? Are they all roughly the same, or are they different? And how would you go about choosing one over the other?

Dr. Oakley: I like where your head's at, so I'll take the efficacy question first, Bruce. We forgot to mention Botox. Botox is a medicine very similar to the daily pill for your bladder. Botox is an injectable medicine that's usually administered in the office every six months to calm the muscle down. So if we talk about Botox, its efficacy rate is somewhere between 80 and 90%, depending on the patient and his or her history.

And I think that's a great point of reference. The nerve therapy's also in line with that. They are usually 82% successful for things like overactive bladder and urge urinary incontinence. A lot of those nerve therapies are used for other pelvic floor issues like fecal urgency and fecal incontinence.

It's controlled by the same nerve, and they are 89% effective for fecal problems. So I think when you take all men and women, all comers, all backgrounds, all medical conditions, when we're talking about urinary issues, these things are all in line with one another in the 80 to 90% success range, which is great.

Bruce Kassover: That, that sounds more than great. That sounds amazing. Now, you know what? This is this does make me think, though. People get very confused by percentages. When you, for example, something as simple as you're watching the weather and they say there's a 30% chance of rain, if you ask people, you get all sorts of crazy different, different thoughts on what that means.

So when you say something is 82 or 89% effective, what does that actually mean for person X who's actually gonna get this procedure? 

Dr. Oakley: That's, that is, you hit the nail on the head there. What listeners or laypeople should know is most medical research when it comes to subjective success, right? Like, how do you measure how someone feels about this? I think you can count how many times you wet your pants in a day, right? And that can be more quantitative versus qualitative. But when we're talking about subjective success, a lot of these percentages are based on you feeling 50% better.

So let's just take an example where I wet my pants 10 times a day and two times at night. If I undergo one of these neuromodulator or nerve treatments, and now I'm only wetting my pants five times a day and one time at night, that's success, right? So that's factoring into that 80 to 90% success range.

Now, you may be sitting here thinking, "Wait a minute. You're still wetting your pants, Susan." And yes, Bruce, I am. And so I think that's what people need to understand is a lot of these numbers cannot account for bad behavior. And I hate to say that out loud, right? 'Cause we're here to help people. We're here to help.

But it is very difficult to offer these wonderful treatments to patients and also be explaining the fact that they're not 100% perfect, 'cause we are not 100% perfect. A lot of times my patients may have had a stroke, Bruce, and I can't reverse the stroke, so they are wheelchair-bound. To a large degree, they're going to have incontinence no matter what.

But can we improve it to the point where they have fewer side effects related to being wet all the time? Can the caretaker have a diminished burden if the incontinence is less? And I think that's really important to know. And a lot of times, we want these treatments, Bruce, but we don't wanna do the right thing to go with the treatment, which is give up coffee, tea, and soda. I know. I hate to say it out loud. 

Bruce Kassover: I was just gonna say that asking people to give up coffee is probably quite a challenge. 

Dr. Oakley: It really is, and so I think just, again, having that transparent conversation where we say, "Hey, Bruce, we can put this implant in and it's gonna help you tremendously, but you're still gonna wet your pants either because you drink a pot of coffee a day, or because you've had a stroke, or you have spina bifida, or cerebral palsy," whatever the neurologic or dietary issue is, right?

And we just have to be very blunt about that and open that discussion up so that our expectations of one another are clear. 

Bruce Kassover: That makes sense and it sounds perfectly reasonable. Now, I did want to ask you a little bit more about the webinar itself. One thing that a lot of people mentioned that really stood out was that, we heard from Amanda, one of your patients. And wondering if you could tell us a little bit about her story and why that was one that you really wanted to share with attendees. 

Dr. Oakley: Amanda's So wonderful. I think she, by nature, is shy, shyer than me. I think by comparison everyone's shyer than me, Bruce. So I think it took a lot for Amanda to allow her story to be shared, and I certainly don't want to speak for her just because I think it's so powerful when it comes from that person.

But speaking with one another beforehand, she was more than willing to share her story, Bruce, because it's one that is so comparable to what so many of your listeners experience, which is, "I'm gonna wait years to bring it up because there's a stigma. I'm ashamed. I'm embarrassed. I don't know that I want to talk about it. I'm just gonna go buy pads."

And then you get over that hurdle and realize the person you brought it up to may not treat incontinence or may not be comfortable pushing you towards a provider who can discuss the treatments. So she really encountered every hurdle that any man or woman has experienced on this journey to find treatment for their incontinence.

And while I hate that she and anyone else has ever been there, it was good for her to share so that our listeners could say, "Oh my gosh, that sounds like me. I've been there. Now I know what to do next." And I think what she really did more than anything else, Bruce, was encourage your listeners to advocate for themselves and to keep asking, and if they don't get the answer that they need or want, to say, "Who can you send me to? I need to see someone else." 

Bruce Kassover: That brings up another important question I wanted to ask you, which is how do you find the right provider? Do you just guess, "Oh I think I have a problem, I'm gonna go to this type of physician"? Or, do you just start with your general practitioner? What is the process to getting in front of the right person? 

Dr. Oakley: Yeah, I think it's all of the things you just said. I certainly have had patients reach out through my podcast and say, "Hey, I've listened to this. Are you taking patients? Can I come see you?" And sometimes I'll say, all the times I will say yes, but sometimes I will need to say, "Hey, your insurance might require a referral be placed by your family doctor or primary care."

So Bruce, I'm just gonna go ahead and make a blanket statement that most people who experience incontinence should maybe start with their primary care or family doctor anyway. If you have a comfortable relationship; you've known each other for a while or you feel comfortable bringing this up even if you're new to each other, start there.

They may be a primary care provider who has experience starting with the first step, medicines and physical therapy, and that's great. That works for over 50% of men and women anyway. But I think if it ever gets to the point where you think, "Okay, I've tried a couple medicines, I've tried the physical therapy, I've tried to give up coffee, it's just not cutting the mustard," then it's okay to say, "Hey, doctor, can you refer me out to a urologist or a urogynecologist or pelvic floor specialist?" 

Bruce Kassover: That sounds like a very sensible and reasonable approach, so I appreciate hearing that. 

Dr. Oakley: I don't think my husband's ever called me sensible and reasonable, so thank you, Bruce. 

Bruce Kassover: Now what I also wanted to do is we did receive a few specific questions from people who did attend the webinar. So I wanted to ask you those because if somebody's asking it, there's a good chance there are other people who wanted to do so as well. So the first question we got is neuromodulation covered by insurance? 

Dr. Oakley: Most part it is. I would say just being in the Cincinnati metro area, I don't wanna speak for other states or insurance plans, but a good general statement is most insurance plans, commercial insurance plans, Medicare and Medicaid, will ask that you try and fail at least two different oral prescriptions.

So that would be trying one pill every day for two months, and then trying a different pill every day for two months. That would be considered a double failure, and then your most insurance plans would allow you to move forward with neuromodulation at full coverage. 

Bruce Kassover: Okay, so there is a bit of a process involved even if the end result is something that's covered. Which I guess is sounds like pretty much everything when you deal with insurance nowadays. 

Dr. Oakley: Yes. That's how insurance works. 

Bruce Kassover: So we got another question. This person was wondering, what about like vaginal estrogen creams? Is that something that is of value to people who are dealing with incontinence? And if so, how do they work? How do you apply them? What about other sorts of hormones that you might be taking either as a pill or a cream? Can you address that? 

Dr. Oakley: A loaded Question, but I'll first start off by saying estrogen cream or topical estrogen is for everyone. So for our listeners, obviously the female ones, we want to reassure them that robust randomized controlled trials and evidence-based research in medicine has confirmed that topical estrogen cream is safe for everyone.

So breast cancer, smokers, blood clots, totally safe to use, and I advise it. I think everyone should use estrogen cream who's a woman. The best way to apply it, in my opinion, is not what's written on the labeling of the box, whether that's branded or generic estrogen cream. So I recommend a nice blueberry-sized dollop on your fingertip, and it should be rubbed at the opening of the vagina, and that should be done every single night at bedtime.

Bruce, I'm a huge fan of saying, "I don't brush my teeth Monday, Wednesday, Friday." That sounds silly. I want toothbrushing to work, so I do it every day. If I want my estrogen cream to work, then you need to do it every day. And nighttime's the best because the assumption is once you put it on, you fall asleep for at least six hours, and you don't wipe it off with toilet tissue like you might during the day.

And that helps decrease the urgency and frequency of urination. Also protects us against urinary tract infections, which is paramount when you have incontinence and you're wearing a little pantyliner or pad that can irritate the area. 

Bruce Kassover: It's really interesting to hear you say that because I know a lot of women are intrigued and interested in the idea of using a cream, but they are afraid.

Hearing that from a real physician who does this every day and knows what she's talking about actually hopefully means something to these people. So that would be great. Now, the next question, a lot of people were wondering about Kegels. Who are they for? Who are they not for? Is... Are Kegels for everybody? 

Dr. Oakley: They're not for everybody, and I'm glad you asked. Kegels is the word we give to describe squeezing or tensioning the pelvic floor muscles. A good analogy or descriptor is if you're sitting on the toilet as a woman and you have a steady stream of urine, can you coordinate your pelvic floor muscles into a squeeze tight enough to stop the flow of urine sort of midstream?

So that's a Kegel. And Kegels are great to help women with a weakness of the pelvic floor. For example , a lazy loose pee hole like we were talking about earlier. If that urethra tube is patent like a stove pipe, then it might leak when you do stressful activities with coughing, jumping, sneezing, and running. And if you can Kegel it a little tighter, you would have less stress incontinence. Kegels also help weaknesses in the vaginal or rectal area of the pelvic floor. So if you have fecal urgency or fecal incontinence, you might be able to squeeze and prevent leakage of stool. If you have vaginal prolapse or a lazy laxity to the vaginal wall, squeezing it can tighten that up.

It's like doing crunches for your abdominal wall, right? Kegels would not be great for overactive bladder or urge incontinence, which was the focus at the beginning of this particular podcast episode. We talked about the spasticity of the muscle, pushing pee out. So if you're kegeling and making it more spastic, you might be making your issue worse. So no, Kegels are not for everyone. 

Bruce Kassover: That's really interesting. So if they're not for, especially for certain people, what about pelvic floor physical therapy? Is that an option for people who do have OAB, for example ? 

Dr. Oakley: For everyone, just like estrogen cream, Bruce. Pelvic floor physical therapy is really required or mandatory in every other country pretty much outside of America.

Americans are a little behind with their buy-in to pelvic floor physical therapy. And in the Cincinnati metro area, we have several specialists who will see men and women with all types of pelvic floor disorders, incontinence after prostate cancer. So again, not just for women. They would see children, men, and women.

And so I do believe in my heart and soul pelvic floor physical therapy is for everybody. And it's never too late, Bruce. If you feel like, "Oh my gosh, I missed the boat. I never did it when I was pregnant or after I gave birth. Should I do it now at the age of 65?" The answer is yes. 

Bruce Kassover: So I guess one of the takeaways from that also is that pelvic floor physical therapy is not just Kegels. 

Dr. Oakley: Oh, sorry. I'm glad you said that. It is not just Kegels. I hear that from a lot of my patients, Bruce. They'll say, "Oh, I downloaded some stuff on the internet. I do my own Kegels," and I think, "Ugh, you wouldn't do your own physical therapy after your shoulder replacement or rotator cuff repair, I don't think."

I can't imagine with my daddy as an orthopedic surgeon that he would ever allow his patients to do their own hip and knee physical therapy after they have a hip replacement, right? That's the reason that there are doctors of PT, so that they can show you how to do it in the right way so you don't further injure yourself.

And I think it's really important for not just our female listeners, but everyone to know that a doctor of pelvic physical therapy may sound a little weird, and going may sound a little overwhelming or daunting, but they are clinicians. This is their niche. This... they'll tell you when to use Kegels, when not to use Kegels.

Sometimes they need to teach you to relax that pelvic floor when you have overactive bladder, Bruce. 

Bruce Kassover: Okay, that's very good to know, and I'm sure that's gonna disabuse a lot of people of a misunderstanding. Now, here's another question we received, and I'm not sure if maybe, I- I'm a little afraid to ask this but what is the Buff Muff method?

Dr. Oakley: Oh my gosh. God love her, there are some just really entertaining personalities in the medical field, and this Buff Muff lady, she's legit. And the Buff Bu- Buff Mu- I can't even say it, Bruce, but it is basically pelvic floor physical therapy, right? So it's just her entertaining way of explaining that pelvic floor physical therapy is not just Kegels, right?

And so, God love her. I think being entertaining draws women, men in, into the discussion, and I think it's amazing that what she does. But it's basically what we already just talked about. Pelvic floor physical therapy is legit. It's clinical, it's medical, and it relaxes you when you need to be relaxed, but Kegels and strengthens you when you need that.

Bruce Kassover: That is very good to hear. You- you're right. You gotta grab people's attention somehow, so more power to her. Another question we got, somebody was wondering about the Emsella chair. Have you heard of the Emsella chair, and if so, what are your thoughts on it?

Dr. Oakley: Yeah. So very superficial knowledge of this. When it was discussed during the webinar, I almost assumed it was this blue light therapy, and I think it's a really hot topic that people are into chromotherapy right now. If I sit in a sauna with a violet light for 20 minutes versus a red light, what is that helping me work through medically?

But my understanding with the Emsella chair specifically is that it's not based in chromotherapy. It's almost more of a magnetic type of chair where the, I think, allure of it is that it can help the pelvic floor without anyone taking their pants off, right? So you keep your pants on, whether you're a man or a woman.

You sit on this chair. It can cost thousands of dollars cash out of pocket, which is its big disadvantage is that not everybody can afford that. So I think we have something simple, keep your pants on, but potentially costly and requires several visits. Now, does the sort of electromagnetic features of this fancy chair help overactive bladder?

It says it does, but clinically I don't see how. The therapy causes your muscles to contract, and I think that would very much help stress incontinence or pelvic floor weakness, which we call prolapse. But I think strengthening the muscles, again, would have the opposite effect on a spastic diagnosis like overactive bladder or urge incontinence.

Like I said at the beginning, I love that things are developed. They sometimes have no evidence-based medicine behind them, but if there's no harm, it's okay to try it, right? 

Bruce Kassover: I think that makes sense. And yeah they actually, there is a place down by me that does a lot of advertising and one of the things they advertise is the chair.

And if I remember correctly, they say, "It's like doing 10,000 Kegels in a minute," or, some- some number like that. So I think that what you're suggesting is exactly what they're, the way they're presenting it. So I guess if Kegels are not right for what you're dealing with, then yeah, maybe it's not the right choice.

Dr. Oakley: Yes. 

Bruce Kassover: Very interesting. So now another question we had is what about prolapse and urge incontinence? Can you give us a little idea about the relationship there? 

Dr. Oakley: Very little, if any, overlap. Prolapse is when your vagina falls out, and that obviously is not related to your bladder in any way.

So I always like to just remind my women in particular that we have three holes . We have a pee hole, a vagina hole, and a rectum. And the middle hole is our vagina, and we use that to push humans out. So the vaginal tissue skin or vaginal wall, however you want to call it, becomes stretched out, just like the waistband on my jeans, Bruce.

And so if my waistband is stretched out and I haven't washed my jeans in a couple months, they may fall down. Same thing with the vaginal skin. You stretch it out, and with increased pressure and gravity over time, it will fall out, and that is prolapse. So prolapse is a simple hernia, and I think once women really start to call it a groin hernia, it makes way more sense that it's unrelated to the bladder, right?

I don't understand where women get the idea that their bladder can prolapse. That's impossible, right? Your bladder cannot fall out of your penis, so my bladder cannot fall out of my vagina. It's just physically humanly impossible.

If we have a weakness in our belly button, it will pop out, and that's a belly button hernia. And if you had a weakness in your sort of side groin, you'd have an inguinal or groin hernia. And we have a groin, it's called a vagina, and there's no greater pressure than pushing a human out of that place, and thus the tissues get weak and fall out.

It's never an emergency, and it's certainly not related to the bladder. Now- Caveat, if your hernia, your vaginal prolapse, is so pronounced and so big that it blocks your first hole from emptying, then yes, you may have retention of urine, 'cause you just can't get it past that big old bulge. And that's when you can have incontinence, because it's just so full, you're skimming off the top, and the leakage is like a full bucket that's , 

Bruce Kassover: I am with you. That makes perfect sense. I love how you reframe it. That really is a helpful way to, to think of things. Now, another question we got is for bowel incontinence, what sort of a specialist do you see there?

Dr. Oakley: I love bowel incontinence. I know, it is so weird. But nobody wants to pee their pants, and nobody really ever wants to poop their pants. And I've done it, Bruce, trust me. I was in the middle of the checkout line at Target and had an attack, is what I like to call it.

Women as a patient, could see a pelvic floor specialist like myself. A lot of people call us urogynecologists, but we are truly reconstructive pelvic surgeons, and that includes that third hole. So we do love to treat fecal urgency and bowel incontinence. And the neuromodulation we talked about for the bladder do help the bowel. If you're a male patient, there are a lot of urologists who will do these nerve implants for male patients, because so many men don't just have bowel incontinence, right?

They tend to have both pee and poop issues concomitantly. But if you don't have a urologist in your area that would treat you for your bowel incontinence, you could see a GI medical doctor or a colorectal surgical doctor. 

Bruce Kassover: That's great to know. Now, you mentioned reconstructive surgery, and another question we had was what is reconstructive surgery even for? When would you need that ?

Dr. Oakley: That's a great... that's a loaded question again, Brooks. You're really putting me to task here. If we go hole by hole, sometimes I need to do reconstructive work for a bladder in the, or the first hole, because it's been injured during childbirth. There could have been a tear in the bladder from traumatic forceps or an emergency C-section, and I would need to reconstruct that so it functions and there's no ill will that happens during the healing process in case someone overlooked that injury.

When it comes to the middle hole, the second hole includes the uterus and the cervix and the vagina and the vulva. So anywhere in there I might need to reconstruct if the patient has been through cancer treatments for something GYN related, or they've been disfigured because of radiation or other cancer surgeries.

And then I could correct that with my own reconstructive surgical techniques. Sometimes, particularly in Africa or in immigrant populations, even in the United States, we'll have women who have been injured by female genital mutilation to that area, and that's something I would need to correct.

Oftentimes it's so intense that they no longer have a functional urethra or pee hole to pee out of. And so that's where, again, I might be fixing the first and second hole at the same time. The third hole can be reconstructed, and the sphincter can be fixed in really severe cases of bowel incontinence or rectal injury, particularly during childbirth.

So that's what you might have heard as a third or fourth degree tear. And those women are more susceptible to pooping their pants 10, 20 years down the road after having children. It's best you reconstruct it now so they don't encounter those issues in the future. There are lots of interesting and intriguing unique cysts and growths and masses in the pelvic floor, and those would be moments where I'm called in for reconstructive surgery as well.

Bruce Kassover: It's fascinating, and it's gotta be very rewarding to be able to help people with surgeries that really produce some dramatic improvements. That's amazing.

Now, we did have one last question also, and I'm guessing somebody just had a prescription written because they are wondering, mirabegron, is that a common medication? And I suppose we could also follow that up with, what are some of the common medications that people might hear prescribed? 

Dr. Oakley: Some of the more common medications that insurance payers will typically cover initially are called anticholinergics. Those branded names that your listeners may be familiar with would be Oxybutynin, Ditropan, Detrol, Vesicare, Toviaz, and Trospium, Sanctura, Enablex. These have been around for 30 years, Bruce, and these are the ones that typically cause dry eye, dry mouth, and some constipation.

There's been a lot of fear coming out of the general population over the past five years that anticholinergics may cause dementia, and that is certainly not the case, and I'd be happy to clarify that in a moment if you ask me again. But I think that's prompted these pharmaceutical companies to create an alternative to that group of medicines for incontinence.

The alternatives are mirabegron, like this particular person asked about. The branded name is Myrbetriq, and Myrbetriq is one of the two beta-agonist or newer medications that don't cause dry mouth, dry eye, and constipation. Beta-agonists are no more effective than the original group of medicines, but I think the fact that the side effect profile is more palatable is what has women requesting those prescriptions, right?

Or maybe it's the fear that the older ones cause dementia, so they're wanting to try the newer ones like Gemtesa and Myrbetriq. 

Bruce Kassover: What is the relationship between the anticholinergics and dementia, if there is any? 

Dr. Oakley: Yeah, I'm not sure that there is a cause and effect, but an association, which I've never really hung my hat on as a clinical provider.

So let's just take, for example, and again, I'm giving loose descriptors of the original research study. But they took 100 women of a certain age, right? And 60, 70 years old, and just asked questions. "Do you have high blood pressure? Do you have diabetes? Are you on... Do you wet your pants? Are you on a pee-pee pill? Do you have short-term memory issues? Have you been diagnosed with dementia?" Lots of things that I think most respondents to the survey said yes to. From that, they extrapolated that there must be an association because everybody was on a pee-pee pill . There was only one at the time. It was called Ditropan. And that everybody had dementia, so oh my gosh, the Ditropan must be causing dementia. And so I don't really see an actual cause and effect from any randomized controlled trial. I think there's just an association there. But that could happen if you survey a very specific population like that with anything, right?

Bruce Kassover: Yes, absolutely. That makes perfect sense. I'm glad to hear that, that may not be the instant ticket to dementia that a lot of people were concerned about. Now, this is Life Without Leaks, and one of the things we always like to ask our guests before we're done is if they have any one little hint, tip, strategy, bit of advice to live a life without leaks. So while we have you, I'm wondering , do you happen to have one that you could share with us today? 

Dr. Oakley: My diet has been everything to my bladder, and I think men and women underestimate what they do to themselves, right? That is my final hot tip for all of our listeners is treat yourself. You are capable of going without the things you thought you couldn't live without.

If you can reduce or give up your caffeine, your carbonation, which is coffee, tea, and soda, you may actually start living a life without leaks just based on simple lifestyle modifications. Now, it's okay if you're listening and you think, "I will never give those up." Then please at least have the courage to ask your care provider if you can be referred to pelvic floor physical therapy, and maybe start an incontinence pill at the very least.

Bruce Kassover: I love that advice, and I'm very encouraged. I'm still not convinced that I'm gonna be able to give up soda, but I'm gonna give it a shot. So thank you. I appreciate that. And thank you for joining us today. I just loved hearing all of your insight and advice, and I hope that everybody who attended the webinar or didn't attend the webinar gets something out of it.

So really, we appreciate it. Thank you for joining us. 

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.