Jocelyn Craig, MD, medical director, Pelvic Health Program at MemorialCare Long Beach Medical Center
Deborah Howell (Host): We've all laughed or sneezed so hard that we've leaked a little, but when the occasional leakage becomes a regular occurrence or soaks your clothing; it's time to see a doctor or a pelvic health specialist to help. Today, we'll talk with an expert about what to do when nature calls a bit too frequently or fiercely.
I'm Deborah Howell, and our guest today is Dr. Jocelyn Craig, Medical Director of the Pelvic Health Program at MemorialCare Long Beach Medical Center. Welcome, Dr. Craig.
Jocelyn B. Craig, MD: Thank you for having me today.
Host: I love that you're here and I love this topic cause so many people have concerns with it. What causes a weak pelvic floor?
Jocelyn B. Craig, MD: So pelvic floor disorders, that term, is a general term to describe dysfunction in the organ systems in the pelvis. So, everybody has a belly button. If you feel down where your belly button is, appreciate that there are multiple organ systems within this space. So there's the bowel, there's the bladder, there's the female reproductive organs, the male prostate.
But also the musculoskeletal system, which includes the bony pelvis and then also the muscles of the pelvic floor. And we often describe those to patients as sort of a basket weave of muscles that contain all these organ systems that I just described. Even sort of like a trampoline because it's supposed to be strong and keep everything contained.
When we're talking about bladder issues, though, there's multiple parts of that as well. So today we're talking about the bladder. There can be dysfunction in the urethra, which drains the bladder and the bladder itself, but also the surrounding pelvic floor muscles can either be too tight or, or weakened.
And, all of this together has the potential for dysfunction. I say all of this because this is a, an example of why a Pelvic Health Center is important because we're looking at multiple organ systems and their function and their dysfunction. So all of this is working together.
Host: Got it. And what are some of the symptoms that you see in your office?
Jocelyn B. Craig, MD: Today talking about the bladder itself, patients will present with leakage and often they don't really know why it's happening. My first comment with them is really to notice what's happening. Tell me about the last time you leaked urine. And I think we're so busy these days, sometimes people don't know why things aren't going correctly, but I ask them, just notice or tell me when the last time was that you leaked.
Was it associated with cough, was it associated with laugh, urgency, physical activity? So these are the kind of things that we see. And then we really need to sort of dissect out what is going on and which organ systems are involved.
Host: And what's the first step someone should take if they're experiencing some of these symptoms?
Jocelyn B. Craig, MD: I think it is just noticing what it is, what the symptom is. Is it leakage, or inability to urinate or inability to have a bowel movement? And usually the first step is seeing your primary physician and from there being referred for a specialty care.
Host: And can you discuss the difference between women and men in weak pelvic floor conditions?
Jocelyn B. Craig, MD: Yes. So men and women get pelvic floor dysfunction. So males and females can get urinary incontinence. Fecal incontinence. They can have dysfunction of the pelvic floor muscles, both of them equally. The difference is that males do not get prolapse, which is basically a herniation of the organs through the vagina. That only occurs in females. But otherwise, all of these things that we're discussing occur in males and females.
Host: Got it. Doctor, why do people pee when they laugh?
Jocelyn B. Craig, MD: So that is an anatomical problem. That is a weakness underneath the urethra, which is the tube that drains the bladder and the bladder itself. The reasons for that can be different. In males, it can have something to do with a prostate. It can have to do with maybe some other surgical or radiation to the pelvis. In females, the most common cause of that, is prior childbirth. So women may not have that issue immediately after they give birth, but sometimes they do. However, as we go through menopause, we lose estrogen everywhere. And estrogen is also very important in the vagina and bladder. The urethra and the bladder have receptors for estrogen, and that's part of what makes the mechanism strong.
So as we go through menopause, we lose that as well. Other factors though that can affect both men and women are chronic cough, chronic weight gain, tobacco use, diabetes. All of these things weaken the tissue around the bladder and the urethra.
Host: And what about post hysterectomy in women?
Jocelyn B. Craig, MD: That can happen, but it's not necessarily the cause of the leakage of urine with cough, sneeze, laugh. One of the things we see as a Urogynecologist is sometimes, again, the overlap of pelvic floor dysfunction. If there's been prolapse and things are coming out through the vagina and they're not well supported, once everything is supported, say the uterus, if it's falling down, it's removed. It often has been masking the fact that the patient also had weak enough tissue that they're leaking urine, and so sometimes after a hysterectomy, urinary leakage begins, not because it was caused by the hysterectomy, but because it was masked by the uterus issue itself.
Host: Okay. That's beautifully explained. Now, what causes overactive bladder?
Jocelyn B. Craig, MD: Overactive bladder is a syndrome of symptoms. It is benign, non-cancerous, and there's a lot of things that cause that. One of them is our habits. We've become a nation of drinking hot beverages like coffee and tea, which is totally fine, but caffeine is a trigger for overactive bladder.
There's good evidence showing that the more caffeine you drink, the more overactive bladder you get. Other things such as citrus or carbonation, things like that, can cause overactive bladder. Medications can cause that as well, right? But again, herein is where these organ systems overlap. Constipation and dysregulation in the bowels can also cause overactive bladder.
Host: So interesting. What treatment options are available?
Jocelyn B. Craig, MD: For overactive bladder, I always start with looking at lifestyle. I have patients often do a diary, which is just 24 hours, looking at their urinary habits, their fluid intake, any kind of leakage they might have. And it's a really good way to sit down and say, what's really happening? Let's not guess anymore. Let's just put it down on paper. And it often can be a surprise to people. They'll say, wow, I didn't realize I urinated 17 times a day, or, wow, I didn't know that I was drinking eight cups of coffee. Um, so starting there and looking at lifestyle is the first thing that we need to do.
As far as treatments, again, modifying some of that lifestyle is important. Sometimes people can get into a habit of urinating very frequently. Maybe they've had an episode where they leaked urine or they were in a setting where they couldn't reach a bathroom. And one of the things that happens is the bladder is a dynamic muscle. It is supposed to fill and empty. And fill and empty. And it gives us triggers, it gives us warnings. But if we learn to respond earlier and earlier to those triggers, the bladder holds less and less.
So one of the things in a normal bladder is doing what's called bladder drills and teaching our bladder to hold more slowly. All right. So that becomes more of a habit and less of a trigger. I also often refer patients to pelvic floor physical therapy because as we started out here, there's, there's often multiple issues that are going on, and then there are medications and there are actual surgical procedures that can be done as well if some of these other issues fail.
Host: Yeah, so you know, I'm a hiker and I was always taught never pass a bathroom, cause you nevere know if an accident. But that's probably not a great idea just to, every time there is one, go in.
Jocelyn B. Craig, MD: Well, I'm not saying that males aren't raised this way, but so many young females have been raised by their mothers. Go to the bathroom just in case. We're leaving the house just in case. And the just in case thing, like I said, often triggers the bladder. Oh, he or she is telling me to go to the bathroom at this point. And so it can often feed into the problem.
Host: And also sometimes the bladder doesn't empty completely in one, one, go.
Jocelyn B. Craig, MD: That's correct. And so, we can also get into a dysfunctional pattern of urination. There's that panic about, oh my gosh, well I need to make sure I'm empty. And then, sometimes patients can learn to do what's called a Valsalva void, where they're really pushing down and bearing down, that's an abnormal way to urinate. So that's where physical therapists come in. We need to reeducate, patients as well as to what is a normal way to urinate. You know, your bladder is filling slowly as you go throughout your day without any trouble. And when you sit down to urinate, the urethra's supposed to open and the bladder pushes it out, but we can create dysfunction in modifying that.
So it's really some education there. One other comment as well is the anxiety. There is an overlap with anxiety with overactive bladder and it makes sense if you have leaked in a public setting, of course there's some anxiety that it could happen again.
Host: Are there medications or supplements to treat this?
Jocelyn B. Craig, MD: So there are medications to treat overactive bladder. There are two main classes of medications. They act differently on the bladder. They also have potential different side effects. Their goal is the same, which is to reduce the urgency to urinate, reduce your frequency of urination, hopefully reduce your nighttime urination, but that's a little bit harder to treat. And then also leakage of urine. They take a while to reach a steady state in your bloodstream to be effective. So patients often need to have some patience to wait until they're be effective. As far as supplements, I'm very careful with that. There are some natural supplements that can help with bladder issues.
However, depending on where you're purchasing these and you know, natural stores, things like that. Sometimes they're mixed with other products which I want to be cautious as far as giving any support to. One thing though, I've noticed is that we have become a nation of people who take vitamins and lots of supplements, and that sounds really great.
But, we as physicians often say, you know, it's best for you to get your nutrients through food. If you're truly deficient in something, then you need a supplement. However, multiple supplements and are just being poured into your urine, and that is actually a very large molecular load to your bladder. So sometimes over supplementation is actually part of the problem.
Host: Oh, you were pointing at me when you said that, weren't you?
Jocelyn B. Craig, MD: Nope, nope. My eyes are closed.
Host: Dr. Craig, are there some other steps that people can take to cope with overactive bladder in their daily life?
Jocelyn B. Craig, MD: Well, one of them is weight loss. There is a definite link with urinary incontinence and overactive bladder. This is a major health issue in our country is weight loss and maintaining a healthy weight. The other is really looking at what kind of irritants we're taking in on a regular basis.
The third is looking at strengthening your pelvic floor muscles and learning how to relax them, but also contract them correctly. And often we're not used to thinking of the pelvic floor muscles. It's not like your bicep, it's not like the muscles in your leg. We don't think about them. But those muscles are active all the time, and if we did think about them, we couldn't do anything else in our day. So that is sometimes why I referred to a pelvic floor physical therapist, just to help the patient make that connection and understand what's going on.
Host: Is this something Pilates or yoga can assist with?
Jocelyn B. Craig, MD: Absolutely. Pilates and yoga also address breathing and diaphragmatic breathing, and that's another thing that happens. We often have sort of a shallow breath right, up in our chest, whereas for pelvic floor strengthening and relaxing, we want to breathe down in the diaphragm. Pilates and yoga can help strengthen. But herein is also the issue. We think about strengthening, but we also see patients that are overly tight. So patients who have overactive bladder sometimes have been contracting so much to try to prevent leakage that their muscles are too tight. All right? And so they shouldn't be strengthening. They should learn to lengthen and stretch. So yes, yoga and Pilates can be helpful. If there is a pelvic floor dysfunction, I really recommend that they see a center that has Medical Pilates as well.
Host: And how soon can a patient see improvement after seeking treatment?
Jocelyn B. Craig, MD: Depends on what we're doing. But in most things, this is either needing to see the recovery from a surgery, it's seeing the effects of medications, which usually takes at least four to six weeks. And then any kind of lifestyle or physical therapy takes some time, right? So, we all know that a habit is supposed to take at least 21 days, right, to be new in your life. I usually don't see patients back for one to two months depending on what kind of treatment we've talked about. And the beauty of all of this is there is, as you can see, a whole spectrum of options.
Host: Lovely. Thank you so much Dr. Craig, for your time and your expertise today. We really, really enjoyed having you on the show. I know I learned a lot.
Jocelyn B. Craig, MD: Thank you for inviting me. I appreciate it.
Host: And for more information, please go to Memorialcare.org/pelvichealth, or call 562-933-8512. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.
We’ve all laughed or sneezed so hard that we’ve leaked a little. But when the occasional leakage becomes a regular occurrence or soaks your clothing, it’s time to see a doctor or a pelvic health specialist to help.
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